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Evaluation Handbook 



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DEMONSTRATION MODEL 



Regional Health Services Research Institute 
University of Texas IHealth Science Center at San Antonio 
7703 Floyd Curl Drive 
San Antonio, Texas 78284 

Prepared under a grant awarded by the Social and Rehabilitation Service, OHEW 





EPSDT - DEMONSTRATION MODEL 
EVALUATION HANDBOOK 



Evaluation Plan, Goals, Common Data Base, Cost Data Collection 
Performance Measurement, Subsystem Definitions, Statistical 
Data Collection Procedures, Standard and Special Studies, 
Standard Reports, Testable Hypotheses, Sample Forms and 
Program of Instruction for Screeners 



Harry W. Martin, Ph.D. - Director 

Harold D. Dickson, Ph.D. - Deputy Director 

Arthur E. Britt, M.A. - Asst. Deputy Director (Primary author) 

Nina Mocniak, M.P.H. - Research Associate 

Fred Fiedler, Ph.D. - Research Associate 

James Titley, B.A. - Data Systems 

William Weston, III, M.D. - Medical Consultant (Section IX-D) 
Laverne Butler - Technical Assistant 



Health Services Research Institute 

University of Texas Health Science Center at San Antonio 
7703 Floyd Curl Drive 
San Antonio, Texas 78284 



May 1 , 1975 



TABLE OF CONTENTS 



Preface 

I. General (Background) 
II. Evaluation Plan and Purpose of Handbook 
III. Common Data Base 

A. Community Baseline Data 

B. Family and Child Health Welfare Data 

C. Cost Data 

IV. Subsystem Definitions 

A. Case-finding Subsystem 

B. Screening Subsystem 

C. Diagnosis Subsystem 

D. Treatment Subsystem 

E. Case-monitoring Subsystem 

V. Testable Hypotheses 

A. Case-finding Subsystem 

B. Screening Subsystem 

C. Diagnosis Subsystem 

D. Treatment Subsystem 

VI . Performance and Cost Measurements; Data Collection 
Procedures and Guidelines 

A. Population and Data Base 

(1) Cohort Groups (If Cohort System Employed) 

(2) If Cohort System Not Employed 

Flow Chart - EPSDT Demonstration Model 

B. Data Elements, Sources and Explanations 

1. Case-finding Subsystem 

a. Performance Measurement 

b. Data Collection Procedures and Guidelines 

2. Screening Subsystem 

a. Performance Measurement 

b. Data Collection Procedures and Guidelines 



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3. Diagnosis and Treatment Subsystem 60 

a. Performance Measurement 

b. Data Collection Procedures and Guidelines 

4. Case-monitoring Subsystem 62 

a. Performance Measurement 

b. Data collection Procedures and Guidelines 

5. Cost Measurement 67 

a. General 

b. Subsystem Non-determinate Costs 

c. Subsystem Determinate Costs 

VII. Special and Standard Sub-studies of Program Impact 79 

A. Standard Studies 79 

1. General Status of Child Health (Annex A) 80 

2. Inmunization Status (Annex B) 81 

3. Seriousness and Type Disease/Injury Conditions (Annex C) 82 

4. Utilization of Community Health Services (Annex D) 83 

5. Medicaid Costs (Annex E) 84 

B. Special Studies 79 

1. Recipient Attitudes (Annex F) 85 

2. Staff Attitudes (Annex G) 86 

3. Provider Attitudes (Annex H) 87 

VIII. Standard Operational and Evaluation Report System 88 

A. Operational Reports 88 

B. Evaluation Reports 93 

IX. Model Forms and Entry Explanation 131 

Family Contact and Screening Appointment Card (Form) 133 

Entry Instructions 134 

A. EPSDT Registration Sheet (Form) 137 

Entry Instructions 138 

B. EPSDT Screening Sheet (Form) 145 

Entry Instructions 146 

Immunization Annex (Form) 159 

Entry Instructions 160 

Flow Chart - Immunization Subsystem 166 

C. EPSDT Problem Referral and Case-monitoring Sheet (Form) T67 

Entry Instructions 169 



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D. Vital Signs, Tests and Measurements - Normal Ranges and 

Gross Indicators of Specific Disease and Injury Conditions 



(Child and Family History and Physical Examination) 182 
(Annex A) 

X . Program of Instruction for Screeners in Use of Forms, Norms, 204 
and Gross Indicators 

XI. Data Processing Instructions 208 

A. General 208 

B. EPSDT Registration Sheet 208 

C. Family Contact and Screening Appointment Card 209 

D. EPSDT Screening Sheet 210 
E Immunization Annex 213 
F. EPSDT Problem Referral and Case-monitoring Sheet 215 

XII. An Example - Overall Research Format - Multiple Demonstrations 218 

XIII. An Example - Research Format for the Case-finding and Case- 
monitoring Subsystems as a Component of a New Demonstration 

in an Urban Setting (A 36-month Projection) 221 



1 

PREFACE 

This handbook is a complete "package" for conducting and evaluating 
EPSDT demonstration projects. It is intended to be viable and transitional. 
This is the second published version, replacing the first dated September 1, 
1974. Changes to this version are based primarily upon practical application 
of select aspects of the Handbook in the ongoing EPSDT demonstration projects.^ 
Other changes are predicated upon discussions with National, Regional, State 
and community EPSDT operating personnel and, also as a result of input from 
several symposiums and workshops concerned with the EPSDT program. It, or 
sections of it, will continue to be republished with reasonable frequency to 
assure its relevance and applicability to specific problems and projects. 

As a guide to those who had received the first version of the Handbook 
(September 1974) the major changes in this version are as follows: 

--Extensive expansion of the section on cost data collection and 
reporting. (Chapter III) 

--New formulas and methodologies have been introduced to evaluate impact 
of variables on population groups wherein pre-set cohorts are not 
used. (Chapter VI) 

—Revision of the overall systems flow chart for the EPSDT Demonstration 

Models. (Chapter VI) 
--Addition of a new chapter on a standard operations and evaluation report 

system (time sequences, content, methodologies, format, etc. ). (Chapter VIII) 
—Addition of a "Family Contact Card" into the case-finding subsystem 

and accompanying instructions. (Chapter IX) 

^Washington, D. C; San Antonio, Texas; Cuba, New Mexico; Contra Costa 
County, California 



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—Revision of the Problem Referral and Case-monitoring Sheet to strengthen 
the case-monitoring (problem and case resolution) systems component. 
(Chapter IX) 

--Addition of a flow chart for the Immunization Sub-subsystem. 

(Chapter IX) 
--Addition of two examples of 

..an overall research format for multiple variables for four site 
demonstrations, 

..an indepth research format for two subsystems of EPSDT in a 36-month 
time projection. 

The addition of the last two items indicated above now gives this Handbook 
a two-fold purpose; i.e., (1) guidance for evaluating EPSDT demonstration models 
(the original purpose) and (2) research design guidance for developing EPSDT 
demonstration proposals (the added dimension). This second purpose has been 
added as a result of numerous contacts with State and local EPSDT operating 
personnel who indicated there was a real requirement for information of this 
nature in the field. Though these two purposes are separable and cduld readily 
be contained in different documents, the determination was made to include both 
in this document in order to have a single ready reference to give to persons in 
the field with prospective interest in new EPSDT demonstrations. 

The goals, objectives and testable hypotheses contained in this Handbook 
are wholly oriented to support the EPSDT program research and development 
objectives established by the Social and Rehabilitation Service, DHEW, for 
FY 75/76. 

The focus of this R&D effort is designed to provide decision makers at 



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National, Regional, State and conmiunity levels with information concerning 
various aspects of local EPSDT operations and their transferability, effective- 
ness and costs in order to make appropriate decisions concerning EPSDT, and 
as related to other competing demands. This Handbook is not intended to be 
utilized as a tool for evaluating statewide EPSDT programs. 



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I. GENERAL 

A. Historical 

The 1967 amendments to Title XIX of the Social Security Act added 
a requirement to Medicaid that was intended to direct attention to the 
importance of preventive health services and early detection and treat- 
ment of disease in children in low income or medically indigent families. 

Through this amendment Congress intended to require states to take 
aggressive steps to screen, diagnose and treat poor children with health 
problems. Congress was concerned about the variations from state to 
state in the rates of children treated for handicapping conditions and 
health problems that could lead to chronic illness and disability. 

Though the program (Early and Periodic Screening, Diagnosis and 
Treatment of Eligible Individuals under Age 21) (EPSDT) has been in 
effect for several years, the Social and Rehabilitation Service (SRS, 
DHEW), the executive agency for the program execution, is still con- 
cerned about the variations in program depth and impact in the various 
states. 

The Office of Planning, Research and Evaluation, working cooperat- 
ively with the Medical Services Administration, SRS, are endeavoring to 
assist the States in their program development and execution by conduct- 
ing a research and development program , including demonstration models, 
to develop and provide information concerning variations in techniques , 
methods, procedures, personnel mixes, health care systems in the 
delivery of EPSDT and their effectiveness and costs in specified 
environments. 



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The University of Texas Health Science Center at San Antonio*, 
under a grant awarded by the SRS, is assisting SRS in arranging for 
and evaluating EPSDT demonstration activities. 
B. Goals 

This evaluation concept is keyed to the long range goal of the EPSDT 
program to improve the health status of eligible children. Not only is 
an assessment of the child's physical and dental health included, as 
well as related diagnosis and treatment for problems found, but an 
assessment of the child's mental and emotional health and development 
is equally considered. Developmental screening tests are under 
development for consideration as special assessment tools for black 
ghetto children, American Indian reservation and Mexican-American 
children in three of the ongoing SRS sponsored EPSDT demonstration 
projects (Cuba, New Mexico; Washington, D.C.; and San Antonio, Texas). 



*Through the Health Services ReSiCarch 



Institute (HSRI) 



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EVALUATION PLAN AND PURPOSE OF HANDBOOK 

To fulfill its commitment to the SRS in terms of arranging for and 
evaluating demonstration models, the Institute has developed a method of 
evaluation that is intended to have applicability to any model in terms 
of measuring the effectiveness and costs of designed variations . Demon- 
stration evaluation will generally be conducted in two phases; Phase I 
will be a period of approximately three to six months to institute data 
collection procedures and establish a data base representative of the 
ongoing activity as it exists and the catchment area baseline rates of 
morbidity and mortality; Phase II will involve the application of varia- 
tions in the component subsystems of EPSDT to develop cost beneficial 
techniques to improve performance and to assess the impact of the. EPSDT 
effort on tKe rates of morbidity and mortality. Toward this end, tKe 
EPSDT system is categorized into five subsystems, i.e., (1) case-finding, 
C2) screening, C3) diagnosis, treatment and, C5) case-monitoring. 

A testable hypothesis and a single primary performance indicator has 
been selected to measure effectiveness and costs in each subsystem. 
Standard and special sub-studies are planned to measure outcome impact 
in other select areas. These are all defined in respective sections of 
the Handbook. 

The purpose of this Handbook is to gather into a single package all 
basic components necessary to conduct and evaluate EPSDT demonstrations 
and to assist personnel in States and communities in the conceptualization 
of EPSDT demonstration proposals (Chapters XII and XIII). As indicated in 
the table of contents, this includes definition of a common data base, data 
input forms, testable hypotheses, primary performance indicators, display 



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of primary indicators ( Chart I, following ), normal ranges for vital signs, 
tests and measurements, gross indicators of specific disease and injury 
conditions, a suggested program of instruction for personnel potentially 
involved as para-professional or paramedic screeners in an EPSDT demonstra- 
tion. Also included is an example (Chapter XII) of a research format 
involving multiple demonstrations, as well as an example of a detailed 
research design for the case-finding and case-monitoring subsystems (Chapter 
XIII). 

In the main, ongoing activities will be collecting most of these data 
elements in one form or another. In a demonstration it will be necessary 
that any items not so collected be reported . All forms and instructions in 
this Handbook are illustrative; they are not mandatory, and may be adjusted 
to meet the specific requirements of individual demonstrations. In some 
rare instances duplicative data systems may be appropriate. The grantor, 
(Social and Rehabilitation Services, DHEW, or the University of Texas as 
its agent) would be expected to underwrite the costs of the superstructure 
required to provide this supplemental data as an element of the grant. 

Personnel to conduct the demonstration will be employed by and under 
the supervision of the local project. The Institute may have a single on- 
site coordinator to assist in resolution of operational policy matters 
between the Institute and the demonstration, and to supervise the accuracy 
and completeness of data being transmitted to the Health Services Research 
Institute for data processing. 

All facets of the demonstration will be committed to a formal contract 
(the grant) between the activity responsible for the demonstration (e.g., 
private contractor, city, county. State government) and the Social and 



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Rehabilitation Service, DHEW. Financing of the demonstration and its 
evaluation will be directed toward the SRS/DHEW 1115 grant mechanism. The 
1115 grant to the demonstration agency will include specifically designated 
funds to pay for the HSRI's involvement. A separate sub-contract will be 
required between the demonstration agency and the HSRI for the evaluation 
and reimbursement as specified in the basic grant. 



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III. COMMON DATA BASE 

The purpose of the demonstration effort is to develop improved and 
cost beneficial methods and procedures for delivering EPSDT to poor child- 
ren for utilization in similar environments in other communities, cities 
and states. 

The common data base is the totality of data elements collected from 
the various demonstrations to permit statistical comparison of findings 
between projects operating under similar conditions to demonstrate trans- 
ferability of results. The major components of these data are (1) 
community baseline information and, (2) family and child health and welfare 
information . 

A. Community baseline data includes standard demographic information con- 
cerning the general and health population of the areas and some of its 
specific characteristics such as Medicaid eligibles by specific areas, 
number of physicians and other categories of health manpower, morbidity 
and mortality rates by categories of personnel, etc. These data will 
normally be available in the offices of the appropriate local govern- 
mental jurisdiction, e.g.. City Comptroller, City Health Department, 
County Welfare Office, etc. Other special categories of optional base- 
line data, such as hospital emergency room utilization and inpatient hos- 
pital discharges, may need to be collected by special sampling studies. 
To demonstrate types of existing health problems that could be either pre 
vented or directed from hospital emergency rooms and inpatient treatment 
to less expensive forms of care, sampling studies should be conducted at 
a representative community hospital most likely serving the target popula 
tion. These data should include (for children aged 0-5, 6-14, 15-21): 



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Emergency Room Utilization - for a given week or other represen- 
tative period and sample: 

Problem No. of No. of 

Category Patients Visits Costs 

Hospital Inpatient Utilization (discharge data for an appropriate 

sampling period): 

Major No. of Average Length of 

Diagnosis Patients Hospital Stay (Days) Cost 

Family and child health and welfare information is data collected at 

the point of patient contact by appropriate welfare and health personnel. 

These data elements relate to the following functional activities 

of EPSDT and are inputted Ccollected) by the following forms: 

1. Registration Sheet 

2. Screening Sheet and Immunization Annex 

3. Problem Referral and Case Monitoring Sheet 

In the main, ongoing activities will be collecting most of these 
data elements in some form, particularly those items relating to the 
registration sheet. In these instances, wherein definitions are the 
same, the Institute will merely develop a collection program to extract 
the necessary data. Under the circumstances in which the data is not 
currently being collected, or definitions differ, a modification of a 
current form or a substitute form, or a modified definition will be 
necessary. The contractor will underwrite the costs of the additional 
data requirement. 

Included herewith are models of the typical forms that may be used 
for data base collection input. (Registration Sheet - page 137, 



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Screening Sheet - page 145^ Immunization Annex - page 15a and Problem 
Referral and Case Monitoring Sheet - pagel6/^. These forms will be 
modified to fit unique local situations. The elements of data collected 
by these respective forms (input documents) are: 
1. REGISTRATION SHEET 
Child 

a . Name 

b. Child's Project I.D. Number 

c. Date of registration 

d. Sex 

e. Date of birth 

f. Address 

g. Medicaid number 

h. Telephone 

i. Length of time on Medicaid (current eligibility) 
j. Means of transportation 

k. Method of Referral 

Mother (or female in loco parentis). and Father (or male 
in loco parentis) 

1 . Name 

*m. Address 

*n. Telephone (at which she can be reached) 

0. Social Security number 

p. Medicaid number 

q. Birthdate 

*r. Occupation 

*Items not essential to Data Base 



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*s. Length of time on present job 

*t. Work hours 

*u. Business address 
*v. Business phone 

*w. Salary 

*x. Other income and sources 

y. Psychic reinforcement available to mother in emergencies 

z. Educational level 
Other 

*aa. Sources of income 

ab. Identification of head of household 

ac. Identification of child's health decision maker 

ad. Source of medical payments 

ae. Identification of siblings in household 
2. SCREENING SHEET 

Identification and Screening Status 

a. Date 

b. Child's name 

c. Child's sex 

d. Child's Project I.D. number 

e. Child's birthdate 

f. Child's Medicaid number 

g. Child's race 

h. Caretaker's name (parent or guardian) if different from child' 

i. Screening sequence 

Original or rescreen 

Visit number in respective sequence 

j. Screening completion status 
*Items not essential to Data Base 



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Previous Health Exposure of Child 
k. Provider type (Private M.D., D.D.S., other, E.R., etc.) 
1. Tests, e.g., (hearing, laboratory, etc.) 
m. Recent hospitalization 

Basic Measurements and Vital Signs 
n. Height 
0. Weight 

p. Head circumference 

q. Temperature (oral or rectal) 

r. Pulse 

s. Respiration 

t. Blood pressure (systolic and diastolic) 
Staff Codes 

u. Identification of training and educational level of staff 
completing certain entries 

V. Last name of primary screener 

Healthiness Rating 

w. Screener's evaluation of current general health of child 

X. Problem categories and conditions* ICDA Range 

Infective Diseases and Parasites 000-136 

(1) Pinworms 

(2) Tuberculosis 

(3) Bacterial infections 

(4) All others in category (Incl. lice, 

diarrhea, V.D.) 

♦Problems indicated are those most commonly associated with children and which 
often represent preliminary or early stages of chronic and costly remedial 

sequelae. 




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(6 

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Nutritional Deficiencies, Endocrine and 

Metabolic Diseases 240-279 

Diabetes 

Nutritional deficiencies (avitaminosis, 
obesity) 

Other endocrine and metabolic diseases 
(hyperthyroidism, etc.) 

Blood Diseases and Blood Forming Organs 280-289 



(8 
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(10 

11 
12 
13 
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15 
16 
17 
18 
19 
20 



Anemias (iron and other deficiencies) 
Sickle cell disease and trait 
Other blood diseases (Incl. purpura, etc.) 
Mental Disorders 290-315 



Behavi oral /emoti onal 
Learning disability 
Mental retardation 
Speech disorders 

Nervous System and Sense Organs 320-389 



Convulsive disorder 

Vision problems, refractive (sight loss) 

Eye problems, diseases (strabismus, etc.) 

Hearing problems (hearing loss) 

Ear problems, diseases (otitis media, etc.) 

Other diseases in category (epilepsy, 
sclerosis, etc.) 

Circulatory System (heart, arteries, 390-458 
lymphatics, etc. 

(21) All conditions (Incl. murmur, 
infarction, etc.) 



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Respiratory System (nose, throat, 460-519 
lungs, etc. 

(22) Acute respiratory infections (colds, 

flu, pneumonia, etc.) 

(23) Chronic respiratory infections 

(frequent recurrences of) 

(24) Asthma 

(25) Hay fever and other allergies 

(26) Other diseases in category (pleurisy, etc.) 

Digestive System (mouth, stomach, 

intestines, etc. J 520-577 

(27) Dental caries 

(28) Other dental and oral problems 

(29) Hernia 

(30) Other diseases in category (colitis, 

peritonitis) 

Geni to-urinary System (kidneys, 

bladder, genitals 580-629 

(31) All conditions (kidney, bladder, 

genitals, etc.) 

Skin 680-709 

(32) All conditions Clncl . impetigo, 

boils, eczema) 

Musculoskeletal (bones, joints, 

connective tissue, etc. 710-738 

(33) All conditions (Incl. skeletal 

deformities, arthritis, etc.) 

Birth Defects 740-759 

(34) All conditions (Incl. cleft palate 

and lip, clubfoot, etc.) 



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Birth Problems (Perinatal) 760-779 

(35) All conditions (Incl. abnormal 

labor and difficult birth) 

Accidents, Poisonings and Violence 800-999 

(36) Lead poisoning 

(37) All other conditions (Incl. fractures 

and other injuries) 

All Other Conditions 

(38) All other conditions (Incl. 

neoplasms, 140-239 
abortion, 630-678 
symptoms) (Enuresis, etc.) 780-796 

. Medical History 

y. Family 

z. Child 

Tests and Measurements (Type, if required, results [normal /abnormal] , 
retests) 



aa. 


Pinworm 


ab. 


Tuberculosis 


ac. 


Urine culture 


ad. 


Urine analysis 


ae. 


Hematocrit 


af. 


Hemoglobin 


ag. 


Sickle cell 


ah. 


Denver Developmental 


ai . 


Other developmental 


aj. 


Vision - Snellen, Titmus, Other 


ak. 


Hearing - Audiometer, Impedance Bridge, Other 


al. 


Phonocardioscan 


am. 


Lead 



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Physical Examination, Observation of all Systems Specified 
in "Problem Categories" and Indication if "Abnormality 
Suspected"^ 

Indication of Whether A "Problem Sheet" Originated by Problem 

3. IMMUNIZATION ANNEX - REQUIREMENTS, SCHEDULING AND CONTROL 

a. Routine immunizations requirements for any child of specific 

age (DTP, TOPV, Measles, Rubella, Mumps) 

b. Status of a particular child's immunization (previously and 

current visit) 

c. Child's immunization requirements (by date, next four months) 

d. Child's receipt of immunizations required to achieve a status 

of "complete for age". 

4. PROBLEM REFERRAL AND CASE MONITORING SHEET 

Identification 

a. Child's project I.D. number 

b. Date 

c. Child's name 

d . Sex 

e. Date of birth 

f. Medicaid number 

g. Parent's Social Security number 
Referral Provider (Practitioner ) 

h. Name of provider to whom referred 

i. Address 

Problem for which Referred 
j. Problem and number for which referred 
k. ICDA category of problem 







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1. Problem status--whether previously known to parents and 
whether previously under care 

Provider's Confirmation. Classification and Resolution of Problem 

m. Date of examination 

n. Confirmation of "a problem" 

0. Confirmation of classification of problem and ICDA 
p. Other classification (diagnosis) assigned (and ICDA) 
q. Determination of whether condition is: 

Acute/chroni c ; symptomati c/asymptomati c 
r. Provider's estimate of severity of condition 
Problem Resolution or Status 
s. Resolved this visit - 

- condition minor— treatment completed; condition now cured or inactive 

- condition presumed cured or inactive within 10 days of this visit 

with treatment prescribed 

- condition noted--treatment (or further treatment or counselling) 

not advisable or unwarranted 

t. Not resolved this visit - 

- remains under treatment (this office/clinic) 

- referral to other practitioner for diagnosis or treatment 

- condition noted, but not treated or referred, because 
. treatment not authorized by plan 

. treatment not locally available 
Case Monitors - Problem Resolution or Status 
u. Appointment status (initial with practitioner) 

- first appointment 

- second appointment 

- third appointment 




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V. Problem resolved 

- condition minor--treatment completed first visit, now cured 

or inactive 

- condition presumed cured/or inactive within 10 days of first visit 

with treatment prescribed (or further treatment or counselling) 

- condition noted; treatment (or further treatment) not advisable 

or warranted 

- treatment plan completed, now cured or inactive 

- treatment terminated, maximum benefit achieved (not necessarily 

inactive or cured) 

w. Problem not resolved 

- still under treatment (original practitioner/clinic) 

- still under treatment (referred practitioner/clinic) 

- condition noted, but not treated, due to 

. treatment not authorized in this jurisdiction 
. treatment not locally available 
X. Other problem termination 

- family declines further participation 

. failure to keep first visit appointments 
. failure to keep extended visit appointments 

- family moved from jurisdiction 

- family no longer program eligible 
y. Case monitor^s source of information 
z. Case monitor's method of follow-up 

aa. Case monitor's tally of total conditions identified and resolved 

ab. Case monitor's skill qualifications 

ac. Date form completed 



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Cost Data 

1 . Cost is a major consideration in the measurement of effectiveness 

of demonstration variables. Without accurate cost data demonstration 
results are of little or no value. 

Consequently, it is necessary to place great emphasis and 
devote considerable time and effort to collect the cost data in 
the detail necessary to satisfy the requirements of the performance 
measurement formulas in Chapters V and VI. 

Two elements of data collection and reporting are, therefore, 
absolute , i.e., 

(1) accurate accounting for employee hours by subsystem or 
designated major activity, 

(2) accurate reporting of total costs per month chargeable to 
specific accounts (as identified). 

2. Phase I will collect data by subsystem and major activity to establish 
base costs with which to compare the variables introduced at sub- 
sequent time periods in phase II. 

3. Categories of Costs 

Costs related to subsystems or major activities will include the 
total dollar charges for specified periods of time for personnel, 
utilities, supplies and equipment, rent or prorated depreciation 
costs, travel, transportation, diagnostic and therapeutic procedures, 
etc. Some of these costs will be readily identifiable with a 
subsystem or major activity Csubsystem determinate or direct costs) 
such as provider charges for therapeutic services to the diagnosis 
and treatment subsystems. Other costs are not so readily identifiable 



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with a subsystem (subsystem non-determinate or indirect costs) 

such as charges for rent, utilities, multi-functional personnel, etc. 

a. Determinate/Direct Costs 

Many cost elements directly and totally relate to specific 
subsystems, e.g., most personnel are hired for specific jobs in 
specific major activity or subsystem areas and treatment costs 
relate directly to the diagnosis and treatment subsystem, etc. 
Yet, even these may not be so readily obtainable. For example, 
treatment costs provided by private providers can often only be 
traced back to a screening finding (or specific child) through 
State Medicaid payment tapes. Additionally, public providers 
of screening and treatment services often do not bill for 
services, yet to obtain true EPSDT costs, these services must 
be costed--even though covered under some other budget program . 
To resolve these problems, certain assumptions and stipulations 
must pertain, e.g. , 

(1 ) Medicaid Reimbursable-Private Providers 

The basic source of these cost data will be State 
Medicaid files of provider charges and reimbursements. For 
screening charges, if these are not established by the State 
on a fixed fee basis, an average cost will need to be estab- 
lished by sampling of screening charges, developing an 
average screening cost and this average cost applied to the 
numbers of children who have completed "screens". For 
diagnosis and treatment charges, names and identifying 
numbers of children known to have been screened will need to 




( 



20 



be tracked through the State Medicaid files of payments to 
providers to find diagnosis and treatment costs for screen- 
ing problems found. Even this will have its complications 
because of the need to relate treatments found in the 
"Medicaid recipients file" to the screen and the conditions 
found in that process. Two assumptions may assist in estab- 
lishing the linkage between these two processes; one is 
an assumption that a treatment provided, within a 90-day 
period following a screening identified problem, is related 
to the screening finding and, two, the problem referral 
sheet (from screening) contains a descriptive condition and 
six digit ICDA code range for the suspected problem condi- 
tion within which it is assumed that the three or four 
digit ICDA code assigned by the practitioner will fall, or 
that a correlation can be established between the descrip- 
tive conditions. Notwithstanding, treatment costs will 
generally have to be based upon "sample" data, or if the 
Medicaid agency has developed a sophisticated "condition 
profile", standard costs (average costs) by condition 
(problem) may be utilizable. 
(2) Public Provider Costs 

In some instances, public providers bill Medicaid for 
services provided for screening, diagnosis and treatment. In 
these instances, the same assumptions or stipulations for 
tracking costs for private providers would apply. In 
those instances in which public providers do not bill or 



( 



( 



21 



charge for diagnostic and treatment services provided Medicaid 
eligible children, a schedule of assigned charges must be 
developed in order to determine true EPSDT costs. This 
schedule should be representative of the type of services 
normally provided children by the representative public 
providers in the demonstration jurisdiction. It may be 
appropriate to utilize the average cost data for these type 
services obtainable from the State Medicaid tapes in order 
to assure the full representative cost of the service which 
is sometimes not reflected in public sector charges because 
of the omission of indirect costs from the charge. If a 
cost accounting system is in effect in the State or community 
in which a demonstration is to operate, these type costs and 
"true" charges will not be difficult to establish. The 
assumption that a private practitioner's charge for a service, 
of necessity, includes a prorated share of all costs associated 
with the operation of his office and facility, is an example 
of the "representative full cost" being sought to effec- 
tively evaluate the EPSDT program. 
Non-determinate/ Indirect Costs 

Non-determinate or indirect costs will be prorated to sub - 
systems or major activities based upon the percent of total 
personnel hours committed to each subsystem . If, for example, 
10 employees work 400 hours in one week and, in these 400 hours 
they reflected the following commitment of time by subsystem 



I 



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i 



22 



or major activity; i.e., case finding (20 hours), screening 
(100 hours), diagnosis and treatment (260 hours) and case 
monitoring (20 hours), then accordingly, non-determinate/indirect 
costs would be prorated at 5% - case-finding; 25% - screening; 
65% - diagnosis and treatment; and 5% - case-monitoring. All 
indirect costs such as rent, gas, electricity, water, telephone, 
transportation, travel, maintenance will be prorated on this basis. 

Additionally, personnel assigned to other areas but contri- 
buting partial supportive effort to the EPSDT program will have 
the costs of their contributive effort prorated on the basis. 
It will, however, be necessary to detail the laws and hourly 
wage rates of all such employees so that these costs may be 
appropriately included in the cost of the EPSDT program. 
Cost Input and Summarization Procedures 

Since the basis of cost proration is significantly predicated 
upon the percentage of personnel time committed to the various 
subsystems and other major activities, it is basic to the costing 
system for each employee to account for all available work time on 
a weekly basis (by day) by major activity. The form (Individual 
Work Sheet) on the following page will be used for this purpose. 
The project must establish procedures to assure that a fully completed 
form is submitted by each employee (full time or part time) each 
week. Similar forms will also be submitted for each volunteer worker. 



( 



( 



23 



INDIVIDUAL WORK SHEET 
(For Computation of Demonstration Cost Data by Activity) 

Name of Employee: Week of^ 

(Monday - Sunday) 

Job Title: ^ 

2 Job Title 

Activity of Assignment: No. Code 



Major Activities 


Total Hrs. 
Avai 1 abl e 
This Week 


Hours ■ Worked Per Major Activity 


Days of the Week 


Total Hrs. 
Worked 


1 


2 


3 


4 


5 


6 


7 


Case-finding 


X X X X X 


















Screening 


X X X X X 


















Diagnosis & Treatment 


X X X X X 
















j 


Case-Monitoring 


X X X X X 




















X X X X X 


















Health Education 


X X X X X 


















Other Exper. Activities 
(Specify 1 . 


X X X X X 


















X X X X X 


















2. 


X X X X X 


















3. 


X X X X X 




















X X X X X 


















Ori entati on/Staff 
Trng, /Staff Conf. 


X X X X X 


















^'lanageri al /Admi ni s . 


^ J 

X X y y X 


t- 1 


1 ' 


1 1 












TOTAL 


4 



















^Job Title must be the same or correlate with one of the designated categories of 
personnel reflected in the weekly summary sheet of cost data--if not the same, 
enter the number code of the category of personnel from the weekly summary sheet 
with which it correlates. 

2 

Activity of Assignment must be the task area for which primarily hired and this 
must be one of the eight "Major Project Functional Activities" identified on the 
SuiTFnary Sheet of Cost Data. 
3 

The total of this column will normally be 40 hours unless a legal holiday occurs 
or the individual is a part time employee (for a specified number of hours). 

^Report as a footnote below the table the number of available hours that were non- 
productive, such as absent/sick, absent/leave (vacation). For example, usually 40 
hours will be reported in the total space under the column heading "Total Hours 
Available This Week". If one day of leave was taken a footnote should indicate 
"Includes 8 hours leave". 




( 



24 



Entry Instructions - Individual Work Sheet 

1 . Week of 

Indicate the weekly period covered by the report - (Monday through 
Sunday), i.e., March 10 - 16, 1975. 

2. Name of Employee 

Indicate full name 

3. Job Title and Job Title Number Code 

The job title entered must be one of 24 contained in the category of person- 
nel section of the Cost Data Summary Sheet (page 27) or identify with one 
of these 24 by the code number indicated on the Cost Data Summary Sheet. 
This correlation is imperative to ready conversion of individual work 
sheet data to summary sheet data . If there is difficulty in fitting a 
job title to one of these classifications. Job Title Code Number 24 may 
be used, which is "Other (specify) ". 

4. Activity of Assignment 

The activity of assignment must be one of the eight "Major Project 
Functional Activities" contained in the Cost Data Summary Sheet, i.e., 
(1) Case-finding, (2) Screening, (3) Diagnosis and Treatment (4) Case- 
monitoring, (5) Health Education, (6) Other Experimental Activities, 
(7) Orientation/Staff Training/Staff Conferences and (8) Managerial and 
other Administrative Activity. This correlation is imperative to ready 
conversion of individual work sheet data to summary sheet data . If 
the "Other Experimental Activity" option is utilized to account for time, 
this activity (or activities) must be identified, e.g., "development of 



( 



( 



25 



a learning disability screening instrument". 

5. Total Hours Available this Week 

The entry will be the number of hours for which paid, normally 40, 
unless a legal holiday occurs in which the total activity is suspended 
or a worker is a part-time employee (for a specified number of hours, 
i.e., 20 hours), or it is the number of hours actually worked by a 
volunteer worker. 

6. Hours Worked, by Major Activity 

(1) Days of the Week 

The total of hours for each day will hormally be eight unless one 
of the exception categories indicated in No. 5, above, applies. The 
total of daily hours will be accounted for by major activity. It is 
assumed that all available (paid) time is productive time and attribut- 
able to one of the major activities indicated. Sick hours (days) or 
vacation hours (days) will be prorated to major activities for a given 
employee, based upon the usual proration of time for that employee. 

(2) Total Hours Worked 

Based upon stipulations already identified, total hours worked should 
usually be the same as total available hours. The exception to this might 
be where overtime is involved. If paid overtime, the total hours avail- 
able should be reflected to show these as additional available hours, and 
then the two total columns will again coincide. If unpaid overtime , the 
total hours worked may exceed the total hours available but all time must 
be distributed by major activity. Unpaid overtime will tend to distort 
true costs if extensively utilized. Under such conditions a cost would 



( 



26 



have to be allocated and charged for such overtime hours. 
Summary Sheet of Cost Data 

Data from individual work sheets will be transcribed weekly to Section 
I - Personnel Data of the Sunmiary Sheet of Cost Data. The form (Summary Sheet 
of Cost Data) on the following page will be used for this purpose. The Project 
Director must assign responsibilities and establish procedures to assure that 
a fully completed form (Section I) is furnished the HSRI on-site Project 
Coordinator each week for the preceding week with a copy of all back-up 
Individual Work Sheets. 

A separate Summary Sheet of Cost Data will be prepared for each quarter of 
the year as of September 30, December 31, March 31 and June 30, and will include 
completed Sections I and II. 

The personnel data in the quarterly reports will be a summary of Section 
I of the 13 weekly reports covering that period. To assure uniformity of 
inclusive dates, the HSRI will indicate quarterly which 13 weekly reports will 
be covered in each quarterly report. The cost data in Section II will be for 
the inclusive dates of the respective quarter. 

The quarterly Summary Sheet will be furnished the HSRI on-site Project 
Coordinator by the 12th day of the month following the end of the quarter 
(October 12, January 12, April 12, July 12) . 

Entry Instructions 

(To understand the explanation on entries, it is imperative that the Summary 
Sheet be constantly in eyesight A partially completed example is provided on 
page 27a) 

Section I - Personnel Data 
1 . Periodicity 

Check one, whether a weekly or quarterly, and fill in the inclusive 
dates which the report covers. 



'0 



28 



2. Category of Personnel 

As indicated in the directions for preparation of the Individual Work 
Sheet (Job Title and Job Title Number Code) all personnel employed in the 
project must be categorized into the 24 categories and Job Title Code 
Numbers specified. Write-in options are provided in Job Title Code 
Numbers 4, 17, 22 and 24. 

3. Base Data - Costs and Hours 

Column 1 : Number of Full Time Equivalents and Category of Personnel 

This column represents the summation of all Individual Time Sheet 
data in "Total Hours Available This Week" converted into full time^ 
equivalents for the categories of personnel utilized in the project and 
categorized into the 24 headings and numbers indicated. If, for example, 
120 hours were reported by three physicians, this represents three full -time 
equivalent physicians (120 r 40 = 3). If 100 hours were reported by 
five part time RN's, this represents 2.5 full time RN equivalents 
(100 r 40= 2.5). 

2 

Column 2 : Total Hours Per Week Available for Work for Each Category 
of Personnel 

This column represents the summation of all Individual Time Sheet - 
"Total Hours Available This Week", by category of personnel. If, for 
example, three physicians reported 120 hours available, 120 hours would 
be reported in column 2, line 5. (These are the total of hours that 
will be accounted for by major activity to obtain the percentages of 
personnel effort committed to each major activity.) 

■^Forty hour week equivalents 
2 

This would be understood to mean "quarter" in the quarterly report 



( 



29 



Column 3 : Individual Weekly Rate of Compensation per Full Time Equivalent 
for Each Category of Personnel 

Enter the weekly compensation rate per individual for each category 
of personnel. If salaries within categories vary, then an average salary 
rate for that category should be entered. If three physicians, for 
example, earn $550, $600 and $650 respectively, enter the average ($600) 
in column 3, line 5. (550 + 600 + 650 = 1800 r 3 = 600). 
Column 4: Total Weekly Personnel Costs - Each Category of Personnel 

For each line (row) representing a category of personnel for which 
entries are made in columns 1 through 3, an entry will be made in this 
column by multiplying the number of full time equivalents (column 1) by 
the rate of individual compensation for each category of personnel 
(column 3). 

Column 5 : Hours Worked per Week by Category of Personnel 

Enter the total hours worked for the week from all of the Individual 
Worksheets in the " Case-finding " activity for each category of personnel 
in which entries are reported in columns 1 through 4. (Comment: The 
row totals for each category of personnel, as reported in columns 5, 8, 
11, 14, 17, 20, 23 and 26, must correspond to the total hours reported 
available for work in column 2. Columns 5^+8 + 11 +14 + 17 + 20 + 23 
+ 26 = column 2.) 

Column 6 : Percent of Total Hours Available for Work Performed in This 
Activity by each Category of Personnel 

For each line (row) representing a category of personnel for which 

entries are made in columns 1 through 5, an entry will be made in this 

column by dividing the numbers of hours worked reported in column 5 by 



30 



the number of hours available for work reported in column 2. (Comment: 

Column 2 represents 100% for the row total; column 5 r column 2 = column 6; 

columns 6 + 9 + 12 + 15 + 18 + 21 + 24 + 27 = column 2 (100%)). 

Column 7 : Total Dollars Attributed to this Activity by Category of Personnel 

For each row in which an entry was made in column 6, an entry will be 

made in this column by multiplying the dollar costs for each category of 

personnel indicated in column 4 by the percent indicated in column 6 

(that part of the total of this category of personnel costs attributed to 

this major activity--case finding). (Column 4 x column 6 = column 7; 

column 7^ + 10 + 13 + 16 + 19 + 22 + 25 + 28 = column 4) 

Columns 8, 9 & 10 (Screening) ; 11, 12 & 13 (Diagnosis and Treatment) ; 
14. 15 & 16 (Case-monitoring) ; 17, 18 & 19 (Health Education)! 
20, 21 &~22 (Other Experimental Activity) ; 23, 24 & 25 (Orientation 
and Staff Training) and 26, 27 & 28 (Mainagement/Other Administrative 
Activitieiy 

These additional seven sections (21 columns) representing major 
project activities will be completed in a manner similar to that de- 
scribed above for the section on Case-finding consisting of columns 5, 
6 and 7. 

The form indicates the respective column relationships to arrive at 
the appropriate percentages and personnel costs related to the various 
major functional activities. 
Section II - Cost Data 

Row - Direct Costs by Subsystem or Major Activity 

The entries in the boxes in this row in columns 4, 7, 10, 13, 16, 19, 22. 
25 and 28 are simply repetitions of the cost totals from the line (row) 
immediately above in the same columns. These are the totals of direct 
personnel costs by subsystem or major activity. 



r 



31 



Row - Percent of Total Hours Available Committed to Each Major Activity 
The entry in the box in column 2, this row, is simply a repetition of the 
entry from the total row in Section I in the same column representing the 
total number of hours per week available for work. This number, in this 
instance, constitutes 100% of the computations of all other sub-component 
entries in this row. The percentage entry in the box in column 6 of this 
row is the percentage that the number of hours from the entry on the total 
row in column 5 is to this overall total. (The total hours per week by the 
respective categories of personnel in the case-finding subsystem [entry in 
the Total row, column 5, Section I] as related to the overall total hours 
per week available for work [entry in the Total row, column 2, Section 
I] or [entry in Total row, column 5, Section I r entry in Total row, 
column 2, Section I = percent of hours worked in the case-finding subsystem] ). 

The entry in the box in this row in column 9 is similarly determined, 
i.e., entry in the Total row, column 8, Section I r entry in Total row 
column 2, Section I = percent of hours worked in the screening 
subsystem . 

The entries in the boxes on this row in columns 12, 15, 18, 21, 24 
and 27 will be similarly determined. 

The percent entries in all these boxes (8, 12, 15, 18, 21, 24 and 27) 
will total to 100%. 

These percentages will determine the subsequent allocations of 
indirect costs . 
Row - Other Direct Costs (Except Title XIX) 

The project accounting system will categorize other direct costs (other 
than personnel costs) into the following accounts for reporting in this 



\ 



( 



32 



system (internally, other more detailed accounts may be desired by the 

Project Director, but these must directly input into the following): 

Supplies and EouiDmpnt 

Including: Office equipment 
Medical equipment 
Office supplies 
Medical supplies 

Other office services (reproduction, etc.) 

Transportation 
Travel 

It is assumed that these items and services are required for 
(requisitioned for or by) specific subsystem/major functional activities 
and that, therefore, funding in these categories is programmed quarterly 
for the fiscal year as is the accounting of expenditures. 

Accordingly, the entries in the boxes in this row in columns 4, 7, 
10, 13, 16, 19, 22, 25 and 28 will reflect the quarterly total expendi- 
tures for these "Other Direct Costs" by the subsystem or major function 
represented. 

Row - Total Direct Costs (Except Title XIX) 

The entries in the boxes in this row are simply the totals of the entries 
two boxes above in the same columns--reflectinq the total of Direct Costs 
(Personnel Costs) and Other Direct Costs. 

Row - Total Indirect Costs 

Row - Distribution Percentage 

In the respective boxes in the " Distribution Percentage Row " simply 

repeat the percentages derived and reflected in the boxes in the respective 

column groups in the row - Percent of Hours Available Committed to each 

Major Activity. The percent entered in the box in this row in column 4 will 

be 100%, etc. 



33 



The project accounting system will categorize indirect costs into 
the following accounts for reporting in this system (internally, other 
more detailed accounts may be desired by the Project Director, but these 
must directly input into the following): 

Utilities (Gas, electricity. Oil, Water) 

Telephone 

Transportation 

Travel 

Rent or depreciated and pro-rated building costs 
Maintenance 

Prorated costs of personnel employed in other activities but 
committing a percentage of their effort to the project 

Other (Specify ) 

The entry in the box in column 4 (Row - Total Indirect Costs) will 
be the total of all indirect costs for the project for the quarter being 
reported. The entries in the boxes in this row in columns 7, 10, 13, 16, 
19, 22, 25 and 28 will be the prorations of the total reflected in 
column 4, based upon the percentages reflected in these same columns on 
the row - Distribution Percentage. 

Row - Total Direct and Indirect Costs (Except Title XIX) 

The entries in the boxes in this row are simply the totals of the entries 
above in each respective column from the rows "Total Direct Costs" and 
"Total Indirect Costs". 

Row - (Title XIX Costs) (Based on fixed fee/rates or sample data) 

There are entry boxes in this row only for the screening and diagnosis 
and treatment subsystems. These data are to be utilized to estimate the 



34 



costs of the screening package as well as costs for diagnosis and treat- 
ment that were not otherwise previously reflected as direct costs . 

These will primarily be in the category of private provider charges 
that are reimbursed under Medicaid (Title XIX) . 

If the private provider is reimbursed in the demonstration juris- 
diction on a fixed fee basis for the screening package, the entry in the 
box in this row in column 10 would be this fixed fee multiplied by the 
number of screens completed by private providers in the quarter being 
reported upon. If a total package fixed fee is not utilized but a base 
fee with add-on costs allowable for specific components of the screen, 
it may be necessary to sample sufficient numbers of patient or provider 
profiles from the State Medicaid data tapes to compute the "average 
charge" for the screen and then use the average as the factor to be multi- 
plied by the number of complete screens to make the entry in the box in 
column 10, this row. Whichever situation prevails, it is necessary that 
a footnote indicate the manner of ascertaining this cost. 

The entry in column 13, this row, pertains to diagnostic and treat- 
ment charges reimbursed by Medicaid under Title XIX. Since, in only rare 
instances will a State or demonstration jurisdiction provide a data 
system that will feed back to the demonstration, private provider diagnosis 
and treatment costs related to problems found in screening, these charges 
(costs) will need to be estimated as an average per problem or an average 
per problem of specific categories. Data for computing these estimates 
will need to be based on sampling of State Medicaid files (provider 
payment tapes or patient profiles). Names of specific children screened 
in the demonstration, determined to have a problem requiring treatment. 



35 



and referred to a private provider for treatment may be tracked through 
Medicaid tapes in the ensuing several months to ascertain treatment 
provided and charges therefor. A sufficient sampling periodically may 
provide data for an appropriate average cost of diagnosis and treatment 
per problem found. Obviously, a more accurate figure would be based 
upon an average cost per type condition found, but this would require a 
fairly comprehensive system be developed for estimating costs. The cost 
for diagnosis and treatment (entry in box in column 13, this row) would 
be the "average factor" times the number of problems resolved (resolved 
through checking any one of the resolution options in Item 2 [case- 
monitor section] Problem Referral and Case-monitoring Sheet) during the 
report period. 

The entry in column 4, this row, is the row total of columns 10 and 

13. 

Row - Total Direct and Indirect Costs (Including Title XIX) 

The entries in these boxes in this row in the respective columns are the 
totals of the entries in these columns from the rows "Total Direct and 
Indirect Costs (Except Title XIX)" and "Total Direct and Indirect Costs 
(Including Title XIX). 



I 



I 




36 

SUBSYSTEM DEFINITIONS 

A. 1. Functional analysis of EPSDT for purposes of data collection to 

facilitate demonstration evaluation and cost analysis as well as 
to establish a foundation for a total systems analysis approach 
to EPSDT reflects five subsystems, i.e.; 

a. Case finding (outreach) 

b. Screening 

c. Diagnosis 

d. Treatment 

e. Case monitoring (follow-up) and data management 

2. The American Academy of Pediatrics recommends the scheduling, 

periodicity and sequencing procedures for screening as indicated on 
the chart on the following page. The actual scheduling, periodicity 
and sequencing will be in accordance with the respective state, city, 
or special demonstration plan. 

B. These subsystems are defined as follows: 

1. Case-finding (outreach) : to inform eligible individuals about the 
EPSDT program and to encourage them to take advantage of the ser- 
vices; to obtain consent from parents or guardians for the child's 
participation in the EPSDT program, and to provide transportation, 
if necessary, for movement of the children and parent/guardian from 
and to the home and screening activity^ 

2. Screening : to perform a health evaluation of the child, through 
observation and tests, to determine those "well" and those with 



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38 



conditions in need of more definitive study. This evaluation will 
include an assessment of immunization and nutritional status. 

a. Guideline "minimal package" for screening* 

(1) assessment of physical growth 

(2) developmental assessment 

(3) inspection for obvious physical defects 

(4) ear, nose, mouth and throat inspection (includes 

teeth and gums) 

(5) screening tests for: 

(a) cardiac abnormalities 

(b) anemia 

(c) sickle cell disease and trait (when appropriate) 

(d) lead poisoning (when appropriate) 

(e) tuberculosis 

(f) diabetes 

(g) infections and other urinary tract conditions 

(6) assessment of: 

Ca) hearing 

(b) vision 

(c) nutritional status 

(d) immunization status 

b. Optional supplement :* 

(1) all of the above minimum comoonents 

(2) supplemental optional tests: 

(a) cardiac scan 

(b) chest x-ray 

(c) blood pressure 

(d) pinworm slide 

(e) urine culture 

(f) serological test 
(9) drug dependency 

(h) stool specimen for parasites, ova and blood 

3. Diagnosis : to confirm and determine the nature or cause of the 
physical or mental disease or abnormality through the combined use 



*Program Regulation Guide, MSA-PRG 21 (DHEW/SRS, Washington, D.C.) June 28, 
1972 



r 



39 



of health history, physical, developmental and psychological 
examinations and laboratory tests and x-rays. 

4. Treatment : to provide health specialists services, hospital and 
clinic services, laboratory and x-ray services, drugs and appliances, 
physical therapy and occupational therapy, speech pathology and 
audiology services and rehabilitative services to prevent, correct 
or ameliorate diseases or abnormalities detected by screening and 
diagnostic procedures. This must include, where appropriate, eye- 
glasses, hearing aids, other treatment for visual and hearing 
defects and dental services. Dental treatment will consist of 
emergency services and preventive and therapeutic services for dental 
disease which, if left untreated, may become acute dental problems 

or may cause irreversible damage to the teeth or supporting structures. 

5. Case monitoring (follow-up) and data management: 

a. Case monitoring : to monitor all cases from the point of "show" 
at screening to assure completion of screening and to assure 
that those classified as unwell* are referred for accomplishment 
of diagnosis and complete treatment of all conditions until they 
are considered "corrected", or having achieved maximum benefit 
from treatment, or are otherwise terminated, e.g., loss of 
Medicaid eligibility, etc., and that all cases due for periodic 
rescreens are rescreened, and complete all associated diagnosis 
and treatment, if indicated. 

b. Data management : 

(1) Individual record: To assure that an individual record is 
initiated and maintained for each child in the system. 
*A problem referral sheet originated 



f 



4 



40 



(2) Case history: to assure that records are initiated and 
maintained current which will document the status of each 
child in the system and which details problems identified, 
results of diagnosis and services rendered by condition, 
and problem and case resolution. 

(3) Data base: to develop and maintain current a base of refer- 
ence data of activities conducted which will allow detailed 
analysis of costs and benefits of the EPSDT program in toto 
and by subsystem in regulatory minimal terms* of: 

(a) cost of screening 

(b) conditions uncovered 

(c) treatment received (by condition) 

(d) cost of treatment 

(e) treatment needed but not available under the State plan 

In order to achieve a more comprehensive analysis 
of the EPSDT program at project level , the data base must 
exceed the regulatory minimum and include all categories of 
systems "input" such as operaing personnel identified by 
skill categories, numbers, and costs, and the amount of time 
devoted to each subsystem, other operating costs and supplies 
and services by subsystem, such "outputs" as procedures per- 
formed (lab tests by type, x-rays, other tests) referrals made 
by type, costs of the various outputs, and such "outcomes" 
of the system as cases completed by diagnosis, costs of 

*MSA - PRG-21 (Para. 5-70-20-B, 12b) June 28, 1972 



r 



41 



such outcomes, etc. This model includes these data 
elements . 

C. Case monitoring (follow-up) is initiated at that point in the screen 
ing subsystem that a case "shows" for screening and continues until 
the case is resolved and/or through the rescreening sequences or 
until such time as the child is dropped from the system due to move- 
ment from the jurisdiction or loss of eligibility. 

D. Data management is initiated at that point in the case-finding 
subsystem that a child is identified by name as eligible for EPSDT 
in the respective jurisdiction and continued throughout the 
existence of the EPSDT program and the eligibility of the child. 



42 



TESTABLE HYPOTHESIS 

Following are the major testable hypotheses for each EPSDT subsystem 
as well as the related assumptions , factors to be tested (variables), 
indicators of performance effectiveness and formulas used to prove the 
hypotheses for prospective demonstration projects, and designated sub- 
components (sectors). 
A. Case-finding Subsystem 

1. Assumption : Altering resources and means committed to outreach 
will vary the costs and screening rate for the eligible population. 

2. Testable Hypothesis : Progressing from a minimum to a maximally 
effective model for EPSDT, the increased application of resources 
(people and dollars) and means for outreach will increase the rate 
of penetration of the eligible population. 

3. Factors to be Tested (selection options for various demonstrations) 

Establish data base on ongoing program (Phase I) 
Caseworker informs at welfare application 
Flyer with check 
Letter from caseworker 

Letter from director, Department of Human Resources 

Letter from director. Department of Social Services 

Letter from director. Department of Health 

Letter from recognized public figure (mayor) 

Letter (registered) from recognized public figure (mayor) 

Telephone call from caseworker 

Home visit from caseworker 



( 



( 



n 

! I 



43 



Incentive payment (to parent-transportation fee) 

Voluntary community organization - case-finding 

Welfare rights organization - case-finding 

Incentive payment - voluntary organization ($ per show) 

Incentive payment - welfare rights organization ($ per show) 

Full time case-finding aide (1 per 1000 families) 

Full time case-finding aide (1 per 500 families) 

Full time case-finding aide (1 per 250 families) 

Full time case-finding aide (1 per 1000 families) + bonus 
$ each show over 20 per week 

Full time case-finding aide (1 per 500 families) + bonus 
$ each child over 20 per week 

Full time case-finding aide (1 per 250 families) + bonus 
$ each child over 20 per week 

School staff routes to screen (mandatory school admission) 

Welfare staff routes to screen (mandatory welfare continua- 
tion requirement) 

Paid newspaper advertisement (mass media) 

Paid TV spots and feature (mass media) 

Paid radio spots and feature (mass media) 

Paid newspaper/radio/TV spots and feature (mass media) 

4. Performance indicator 

a. Indicator : The number of EPSDT screens initiated as a percent 
of those eligible is a primary indicator of performance 
effectiveness of the case-finding subsystem. 

b. Formula 

No. of eligibles that "show for screening" = Rate (%) of shows 
Total No. of Medicaid eligible children for screening 

(penetration rate) 



44 



Case-finding subsystem operating costs = Average cost per "show for 

Number of shows for screening screening" at rate of 

shows for screening. 

Screening Subsystem 

1. Assumption : Altering the qualifications of personnel performing 
screening will vary the costs and accuracy of screening findings. 

2. Testable Hypothesis : Progressing from a minimum to a maximally 
effective model for EPSDT, the increased qualifications of personnel 
performing screening will increase the accuracy of f indings--(but 
at some point not sufficiently to justify the additional costs). 

3. Factors to be Tested (selection options for various demonstrations): 

Establish data base on ongoing program 
School health aide 

Voluntary hospital-incentive rate, screening (+$10) 
Private sector physician-incentive rate, screening (+$10) 
Health aides + LVN or LPN supervisor 
Health aides + RN supervisor 
Health aides + PA supervisor 
Health aides + MD supervisor 
LVN/LPN's + MD supervisor 
RN's + MD supervisor 

Comprehensiveness of service - screen only 

Comprehensiveness of service - screening, diagnosis & treatment 
Comprehensiveness of service - SD&T + full welfare service 

4. Performance Indicator : 

a. Indicator : The number of confirmed findings of "well" and 




(Ill 



45 



"unwell"* as a percent of the total number of findings of "well" 
and "unwell" is a primary indicator of performance effectiveness 
of a group of screeners in the screening subsystem, 
b. Formula : 

No. of confirmed findings of "well" and "unwell " = Rate (%) of 
No. of findings "well" and "unwell" confirmed findings 

(In total of completed screens) 

Screening subsystem operating costs = Average cost per screen con- 
No. of screens completed pleted at ^rate of 

confirmed findings 

*"Well" is defined as--no problem sheet originated. "Unwell" is defined 
as--a problem sheet originated (Rates of true positives and negatives 
as contrasted with rates of false positives and negatives). 

Diagnosis and Treatment Subsystem 

1. Assumption : Altering the resources and means committed to health 
care of children with health problems will vary the outcomes. 

2. Testable Hypothesis : Progressing from a minimum to a maximally 
effective model for EPSDT, the increasing commitment of resources 
for diagnosis and treatment will increase the number of successful 
outcomes (conversions to well). 

3. Factors to be Tested (selection options for various demonstrations) 

In the respective State of demonstration, should limitations of 
services or dollars for treatment prevail, start with the currently 
allowable services or dollars as the minimum and build to a full 
scale of services in the demonstration. For example, in a State 
limiting dental care (services), the provision of full dental services 
should have a significant impact on the number of cases that could 
potentially be categorized as well. 



46 



Another testable factor is to increase the federal share of 
Medicaid costs (dollars) to ascertain its impact on the range of 
services provided and on the outcomes, e.g., in a State matching at 
50% of the Federal share increase the demonstration costs to 
represent the Federal share at 




Test the organizational impact uoon outcome of screening being 
located in one geographical area and diagnosis and treatment in 
another, as compared with all three activities being located in 
the same area. 

Establish data base on ongoing program (Phase I) 

Limited services - State plan 

Private sector referral 

Public sector referral 

Increased Medicaid reimbursement rates for diagnosis & treatment 

Increased federal sharing of Medicaid costs 
Limited services - State plan 
Full services (demonstration reimburse) 
Increased Medicaid reimbursement rates for D&T 
Increased federal sharing of Medicaid costs 

No increase in Medicaid reimbursement rates for D&T 
Performance Indicator : 

a. Indicator: The number of conversions to well of confirmed 



J 



( 



47 



chronic health problems* as a percent of the number of confirmed 
chronic health problems is a primary indicator of performance 
effectiveness of the diagnosis and treatment subsystem (health 
care delivery system). 

Repeat the hypothesis for acute conditions, 
b. Formula : 

No. of "unwells" converted to "well" = Rate (%) of conversions 
No. of confirmed unwells to well 

Diagnosis & Treatment Subsystem Operating Costs Average cost per 



*This relates to individual problem sheets as distinct from a "child" or 
a "case" which may have multiple problems identified. These latter 
indicators are evaluated in the case-monitoring subsystem following. 

Case-Monitoring Subsystem 

1. Assumption : Altering resources and means committed to case-monitoring 
will vary the costs and case-completion rates. 

2. Testable Hypothesis : Progressing from a minimum to a maximally 

effective model for EPSDT the increased application of resources 

(people and dollars) and means for case-monitoring will increase the 

rate of completions for: 

"problem resolution" ( problem completion) 
"shows for screening" ( screen completions) 
"confirmed unwells" ( case completions) 
"eligibles for rescreens" ( rescreen completions) 

3. Factors to be Tested (selection options for various demonstrations): 



(Operating & Medical) 



= diagnosis & treat- 
ment to convert to 
"well" at rate of 



No. of conversions to well 



conversions to well 



Establish data base on ongoing program (Phase I) 



Case worker is case monitor 



Case worker - new position, 1 per 1000 families 




V 



48 



Case worker - new position, 1 per 750 families 

Case worker - new position, 1 per 500 families 

Case worker - new position, 1 per 250 families 

Case worker - new position, 1 per 100 families + bonus $5 
for each case completion over 20 per week 

Case monitor - new position, 1 per 750 families + bonus $5 
for each case completion over 20 per week 

School health aide is case monitor 

School health aide plus clerical assistant - case monitor 
Performance Indicator : 

a. Indicator : The number of case completions ( al 1 problems resolved, 
per child) as a percent of the number of confirmed unwell cases 

is a primary indicator of performance effectiveness of the case 
monitoring subsystem. 

Repeat the hypothesis for "shows for screening" and 
"problem completions". 

The number of rescreens completed as a percent of the num- 
ber of children eligible for rescreen is a primary indicator of 
performance effectiveness of the case-monitoring subsystem as 
it relates to rescreens. 

b. Formula : 

Rates 

Rate of problem completions (of confirmed problems) = % of problem 
Number of confirmed problems completions of 

confirmed problems 

No. of case completions (of confirmed unwells )= Rate (%) of case 
No. of confirmed unwell cases completions of 

confirmed unwell s 



( 



49 



No. of screens completed = Rate {%) of screen completions of 
No of shows for screening "shows for screening" 

No. of rescreens completed Rate (%) of rescreen completions 
No. of eligibles for rescreens 

Costs 



Case-monitoring subsystem operating costs* = Average cost per 
No. of confirmed problems completed problem completion 

at rate of 

problem completions 

i 

Case-monitoring Subsystem Operating Costs* = Aver, cost per case 
No. of cases completed (confirmed unwells) completion of confirmed 

unwells at ^rate case 

completions 

Case-monitoring Subsystem Operating Costs* = Aver, cost per screen 
No. of screens completed completion of the total 

shows for screening at 

^rate of screen 

completions 

Case-monitoring Subsystem Operating Average cost per rescreen 

Costs* for Rescreens = completion at ^rate of 

No. of rescreens completed rescreen completions 

*As prorated to the respective component of activity in the case- 
monitoring subsystem 



d 



i 



'1 



50 



VI. PERFORMANCE AND COST MEASUREMENTS; DATA COLLECTION PROCEDURES AND 
GUIDELINES 

A. Population and Data Base 

(1) Cohort group (if cohort system employed) 

The list of Medicaid eligible children must identify with a 
specific jurisdiction (census tract, precinct, borough, county, 
etc.) for which the EPSDT demonstration activity has area/population 
jurisdiction (catchment). This is the base against which case- 
finding--the penetration efforts--will be measured. The list must 
be current and an updated version furnished the Institute at a 
prescribed periodic basis, e.g., monthly, quarterly, or semi-annually. 
The system identifiers of an individual in the base and cohorts 
will be the (1) Medicaid number, (2) name and, (3) age or birthdate. 

From the current list of Medicaid eligibles, appointments for 
screening are made. During the next three months appointments are 
also made for those added to the list because they are newly eligible. 
By the end of three months a cohort is identified as those children 
having showed for screening. This group No. 1 is used for eval- 
uation of activity in the five subsystems for an indeterminate 
period of time. At the end of three months a record eligibility 
list is provided of children not screened. The list No. 2 are the 
eligibles remaining from the list who had not "shown for screen" at 
the time of cohort No. 1 and any newly eligible. Screening appoint- 
ments are made from this list. Those who "show for screen" are 



I I 



51 



identified as cohort No. 2 for evaluation of activity in the 
five subsystems. Evaluation is done on the cohorts both separately 
and combined. At these same three month intervals, additional 
eligibility lists and cohorts will be established and processed. 
At bi-monthly intervals a new list of Medicaid eligibles will be 
furnished by the contractee. Each applicable cohort will be 
"purged" of those in the original cohort who are no longer "Medi- 
caid eligible". These individuals, however, will be evaluated in 
any subsequent subsystems through which they have passed before 
losing eligibility. 

A diagram showing the flow of the cases through the five 
subsystems is given in the illustration on the following page. 
A numerical example is provided at the end of this section of the 
handbook. 

(2) If cohort system not employed: 

A separate formula is provided for performance measurement and 
cost analysis in each subsystem should the cohort system, as herein 
described, not be used in a particular project (or part of the project). 
The population base in these instances will relate, as indicated, to 
eligibles at. a specific point in time (the end of a report period), 
or a tabulation of specific actions for a specific and/or cumulative 
period (number of problem sheets completed--resol ved or terminated), 
or an analysis of a sample population over time, etc. 
B . Data Elements, Sources and Explanations 

This section contains a reiteration of the performance indicators 



a 



( 



'■Tl 



1^ 





I 



FLOWCHART 




53 



and formulas used to determine levels of effectiveness and, in 
addition 

(1) comments upon the methodological approach to variations to be 
tested, 

(2) defines each factor (element) of the formulas, and 

(3) lists its location (source document). 
1 . Case-finding Subsystem 

a. Performance measurement 

Indicator: Rate of "shows for screening" (penetration 
rate) per average cost per show. 
Formula to determine penetration rate and average cost per show : 
(If cohort system employed) 

# of "shows" # of "shows" of # of "shows" of 

RATE : of eligibles + now^ not eligible + newly^ eligibles = % (rate) of "shows" 

# currently eligible + # of shows of now not eligible for screening 

Operating costs . . case-finding subsystem Average cost per "show 

COSTS : No. of shows for screening during report period for screening" at 

(Total of numerator in the above rate formula) rate of shows for screening 

^At end of report period (lost eligiblity during report period) 
^Gained eligiblity during report period 

(If cohort system not employed) 

# of "shows" of eligibles 

RATE : # eligibles on last day = rate of "shows" for screening" 
of report period 

COSTS : Operating costs--case finding subsystem = Average cost per show for 

# of shows for screening during report period screening at rate of 

shows for screening 

Comment: In initial stages, a demonstration model may reflect, 

for example, a 10% rate of "shows for screening" (the penetration rate) 



54 



at $.15 per average cost of "show". A problem to be resolved in a 
demonstration might be, "What is the cost of achieving a 25% penetration 
rate?" or, "What would be the impact on the penetration rate of a 
specific change in procedure or personnel to reduce costs in the 
subsystem?" 

b. Data collection procedures and guidelines 
Case-finding subsystem (Rate of "shows") 
(If cohort system employed) 

Factor : Medicaid eligible population in the demonstration 
area. 

Source document : List of Medicaid eligibles 
Comment : Evaluation will relate to the cohort groups 
discussed above. 

Factor : Number of eligibles that "show for screening". 
Source document : Screening sheet 

Comment: A "show for screening" will be any eligible child 
for whom a screening sheet has been initiated as reflected by 
an entry on the sheet of the Medicaid number, name, and age, 
and any one or more additional screening steps initiated, e.g., 
entries in the Medical History columns, entries in the Tests 
and Measurement columns, or entries in the Physical Examination 
column. 

(If cohort system not employed) 

If the cohort concept is not used in this project the rates 
of shows will be based upon the number of children that "show 
for screen" of a list of eligibles as of the last day of the 



I 



55 



report period. If, for example, there are 600 children not 
previously screened''' still active and eligible in the project 
as of December 31, 1974 and 100 of these childern have shown 
for screen during the three months of the report period, the 
rate of penetration is 17% in that quarter (with those techniques) 
and the costs for outreach (case-finding) must relate to the 
same time period to reflect the "cost per show" at this rate. 
Report separately those children who "showed for screen" during 
the period but were not on the list of eligibles as of the last 
day of the report period. This figure will be utilized in con- 
junction with those eligible as of the last day of the report 
period that showed for screen to compute a "cost per screen" in 
this subsystem for the period that is independent of the rate. 
For example, in addition to the 100 "shows for screen" that 
are still active and eligible on the last day of the report 
period, 25 others "showed for screen" during the quarter but are 
not active or eligible on the last day of the report period 
(moved from the area or Medicaid eligibility expired during the 
quarter), these would be totaled (100+25=125) and utilized to 
compute the actual average cost per show for the period 

(" cost per show " = average cost per show). This method is 
125 

utilized to avoid the more complex procedure of attempting to 
keep track of additions and deletions to the base population 
(the eligibles) during the report period and the results of 

In some earlier quarter 



56 

penetration efforts in these categories (additions and deletions) 
in order to achieve a "pure" rate and average cost. 
2. Screening Subsystem 

a. Performance measurement 

Indicator: Rate of confirmed findings (well and unwell) 
per average cost per screen. 

No. confirmed findings "well" and "unwell" = % (rate) of con- 
No. findings "well" and "unwell" firmed findings 
(In the total of completed screens) 

Operating and medical related costs* Avg. cost per screen 

- Screening subsystems = completed at rate 

No. of screens completed of confirmed findings 

Comment: This is a qualitative as v/ell as quantitative 

function. A given mix of personnel, tests and equipment to 

"screen" will produce a derived rate of functional accuracy 

(findings of "well" and "unwell") at a specific cost. A 

"professional review board" will do a 15% sample of the same 

children with the same tests and equipment to establish an 

independent rate of functional accuracy (findings of "well" and 

"unwell") which will be used to determine a rate of conf i rmed 

findings relative to the demonstration screening team's findings 
In initial stages a demonstration model may reflect, for example 
an 85% rate of confirmed findings at $8.00 per average cost of 
a completed screen. A problem to be resolved in a demonstration 
might be, "What are the costs of achieving a 90% or 95% rate of 
confirmed findings?" or "What additional costs, in more precise 
equipment and/or higher qualified personnel, are incurred in 
achieving a 90% or 95% rate of confirmed findings?" 

*Subsystem identified costs for personnel, utilities, rent or construction, 
medical supplies and equipment, screening (diagnostic procedure), other admin- 
istrative costs, and supplies and equipment. 



(IF 



57 



Data Collection Procedures and Guidelines 
Screening Subsystem (Rate of confirmed findings) 

Factor : Number of findings of "well" (no problems suspected) 
and "unwell" (problems suspected). 

Source Documents : Screening sheet 

Definition : 

Category "Well" - No entry of abnormality suspected or 
problem sheet originated in the two right hand columns of 
the sdpeening sheet (67 possibilities). 

Category "Unwell" - Any entry of abnormality suspected 
or a "problem sheet" originated in the two right hand 
columns of the screening sheet (67 possibilities). 
Factor : Number of confirmed findings of "well" and "unwell". 
Source Document : Screening sheet 

Comment : A sample of approximately 15% of all "shows for 

screening" -wil 1 be randomly selected. No indication of this 

selection will be provided to the screening personnel. Upon 
completion of the initial screening sequence by the basic 

screening team, the randomly selected children will be given a 

new screening sheet that will be appropriately coded and these 

children referred to a "professional review board". The 

review board will complete all items on'the screening sheet. 

The same criteria for "well" and "unwell" apply as described 

above. 

The same laboratory reports will be used by both screening 
activities to ascertain presence or absence of problems and 




(I 



58 



abnormalities (well or unwell). 

The completed screening sheets of the basic screening team 
and the professional review board will be compared. A comparison 
of the 67 screening entries in the two right columns of the 
screening sheet (designating a condition of "well" (no abnormal- 
ity suspected) or "unwell" (abnormality suspected) will be made 
from these sheets and a rate of confirmed findings established based 
upon the number of non-deviant entries recorded. As an example, 
if 30 complete screens are processed for the sample this repre- 
sents a total of 2,010 (30x67=2,010) possible findings of "well" 
and "unwell". If the basic screening team designates 1,400 
"well" findings and 610 "unwell" and the professional review 
board confirms 1,300 "well" and 550 "unwell" findings, this 
represents, in gross terms, a rate of confirmed findings of 92% 
In those instances in which the professional review deter- 
mines an initial findings of unwell to be well, the case will be 
processed as a "well case" thereafter, and vice versa for those 
with an initial finding of well. 
(If cohort system not employed) 

If the cohort concept is not used in this project, the rates 
of confirmed findings (unwell) will be based upon the number of 
conditions diagnosed (referred and diagnosed) during the quarter, 
and the numbers of these that had an unwell condition confirmed. 
If, for example, 210 problem sheets were returned during the 
three months of the report period and 190 were confirmed as 
problems, the rate of confirmed findings (unwell) would be 90% 



59 



(190t210=90%) at a specific average cost per screen (the cost of 
operating the screening subsystem for the period). 

If a quality control procedure is in effect to measure 
false negatives, the rate of confirmed findings (well) will be 
based upon the number of "well" children found and confirmed as 
"well" by the quality control procedure (professional rescreen) 
during the period. If, for example, there are 400 children 
found "well" by the screening procedure during the quarter and 
the quality control rescreen of a 15% sample of these (60) 
confirms 50 as well, the rate of confirmed findings of well 
would be (50^60=) 83%. 

The overall rate of confirmed findings (well and unwell) 
would be 86% based upon (210+400=) 610 total findings of unwell 
and well, and (190+332 [400x83%*=332]=) 522 confirmed findings 
(522^610=86%). This rate will be used in conjunction with 
costs to operate the subsystem during the report period in 
terms of the "average cost per screen". 
♦Application of the sample rate (83%) to the total of wells. 
3. Diagnosis and Treatment Subsystem 
a. Performance Measurement 

Indicator : Rate of conversions (unwell to well) per average 

cost per problem for diagnosis and treatment. 

No. of "unwells" converted to "well" _ % (Rate) of conversions to 
No. of confirmed "unwells" well 

Operating and Medical and Related costs* Avg. cost per diagnosis 

Diagnosis and treatment subsystem = and treatment to convert 

No. of conversions to well to "well" at rate of 

conversion to well 

♦Subsystem identified costs for personnel, utilities, rent or construction, 
medical supplies and equipment (diagnostic and therapeutic procedures), other 
administrative costs, and supplies and equipment. 



( 



60 



Comment : A given system of health care delivery may produce 
conversion rate of 85% at an average cost per conversion of $110. 
Local, state, or federal constraints on dollars (per case) or 
treatment may preclude attainment of a 100% conversion of con- 
firmed unwells to well. Nevertheless, a problem to be resolved 
in a demonstration might be, "What are the costs involved in 
increasing the rate of conversion to well of 90% or 95%?" or 
"What would be the impact on the conversion rate of a change in 
a specific constraint at a specific additional cost?" 
Data Collection Procedures and Guidelines 
Diagnosis and Treatment Subsystem (Rate of conversions) 
(If cohort system employed) 

Factor : No of confirmed unwells 

Source Document : Problem Referral & Case Monitoring Sheet 

Comment : Subsystem II (screening) will produce a problem 

sheet for all children categorized as unwell (problem suspected 
or abnormality suspected warranting further evaluation). All 

"unwells" will be referred to an appropriate health care provider 
by a referral sheet. The provider will indicate in some in- 
stances a "non-confirmed" finding of "unwell" when the referral 
sheet is returned to the screening facility. These cases will 
thereafter (where no problem or abnormality suspected with prob- 
lem sheet remains) be categorized as "well" and processed 
accordingly. The remaining confirmed "unwells" constitute the 
base of comparison in this evaluation . 

Factor: Number of unwells converted to well. 



>1 



61 



Source Document : Problem Referral & Case-Monitoring Sheet 
Consent : A problem will be considered converted to well 
following diagnosis (as unwell) and treatment when any one of 
the items in paragraph 2(a, b, c, or d) of the case-monitors 
section of the Problem Referral Sheet (lower third) has been 
checked (/). 

(If cohort system not employed) 

If the cohort concept is not used in this project, the rates 
of conversion to well or inactive will be based upon the number 
of problem sheets pertaining to chronic conditions that are 
returned by practitioners during the last six months prior to 
the end of the report period and the number of these that had 
the problem resolved during this period. 

If, for example, during the six months prior to the end of 
the report period, 180 problem sheets pertaining to chronic con- 
ditions are returned from practitioners, of which 100 achieve 
problem resolution and 25 of these indicate the resolution as 
( / I Treatment plan completed, now cured or inactive (Item 2d of 
Case Monitors Section, Problem Referral and Case Monitoring 
Sheet), the rate of conversions--chronic conditions, unwell 
converted to well or inactive is 25% (25t100) for this six 
month period at a specific average cost per case (chronic 
condition) for diagnosis and treatment.* 

A second and third factor reflecting the rate of conversions 
to well of chronic conditions at the the end of 12 and 18 

*It is assumed that the remaining 75 are resolve'' as [7] Not cured, 
but maximum improvement achieved (condition still active) 




( 



62 



months respectively, will also be utilized. 

These will be based upon samples of problem sheets which 
identified chronic problems in the period 7-12 and 13-18 
months prior to the last day of the report period and are 
still active or elgible in the project. 

One hundred problem sheets will be identified in each 
category (of time) and these will be surveyed to ascertain the 
number resolved during the ensuing period. If, for example, 
75 of the 100 representing the 7-12 month period and 95 of 
the 100 representing the 13-18 month period had reached reso- 
lution by the last date of the current report period, the rates 
would be 75% and 95% respectively, at average cost for chronic 
problem completed identified with these respective time periods. 
4. Case-Monitoring Subsystem 
a. Performance Measurement 

Indicator: (1) Rate of problem completions of confirmed 
problems per average cost per problem completed. 

(2) Rate of case completions of confirmed unwells 
per average cost per case completion. 

(3) Rate of screen completions of "shows" for 
screening" per average cost per screen completed. 

(4) Rate of rescreens completed per average 
cost per rescreen completed. 

No. of problem completions (of confirmed 

problems) ^_ = % (rate) of problem completions 

No. of confirmed problems (sheets) of confirmed problems 



(J 







63 



Operating costs* - Case monitoring Average cost per problem 

subsystem ^_ = completion (of confirmed 

No. confirmed problems (sheets) problems) at rate of 

completed problem completions 



No. of case completions (of confirmed % (rate) of case comple- 

unwells) _ tions of confirmed 

No. of confirmed unwell cases ~ unwells 

J', 

Operating costs* - case monitoring subsystem _ Aver, cost per case 
No. of cases completed (confirmed unwells) completion of con- 
firmed unwells at 

rate of case 

completions 



No. of screening completions _ % (rate) of screen completions 
No. of shows for screening ~ of "shows for screening" 

Operating costs* - case monitoring Avg. cost per screens com- 

subsystem pleted of "shows at screening" 

No. of screens completed at rate of sCPSgn 

completions 



No. of rescreens completed _ Rate (%) of rescreen completions 
No. of eligibles for rescreens 

Case Monitoring Subsystem Operating Aver, cost of rescreens 

Costsf for Rescreens completed at rate of 

No. of rescreens completed ~ rescreen completions 

Conmient : In initial stages a demonstration model may 
reflect, for example, a rate of case completion of 80% for the 
confirmed unwells at .75 per average cost of case completed. A 
problem to be resolved in a demonstration might be, "What addi- 
tional costs for additional personnel, more highly skilled per- 
sonnel, or equipment additions or changes are incurred to achieve 



*Subsystem identified costs for personnel, utilities, rent or construction, 
other administrative costs or supplies and equipment as apportioned, respectively, 
to the case monitoring activities of problem, case, screening and rescreen 
completions, based upon the percent of total case monitor time devoted to these 
respective activities in the period for which the report is submitted. 



64 



an 85% or 90% rate of case completions of confirmed unwells?" 
The same type problem resolution would apply to "screens com- 
pleted of the shows for screening" and "rescreen completions 
of the eligibles for rescreens". 
b. Data Collection Procedures and Guidelines 
Case-Monitoring Subsystem 

(If cohort system employed) 
Rate of Problem (sheet) Completions of Confirmed Problems 
Facto r: No. of confirmed problems 

Source Document : Problem Referral & Case-monitoring Sheet 
Comment : Those problems confirmed as unwell in the practi- 
tioners section (middle third) of the problem referral sheet. 
Factor : Number of problem completions (resolutions) 
Source Document : Problem Referral & Case-monitoring Sheet 
Comment : A problem will be considered completed when any 
of the items in paragraph 2 (a, b, c, d or e) of the case-monitors 
section of the Problem Referral and Case-monitoring Sheet (lower 
third) has been checked (/). 
Rate of Case Completion of Confirmed Unwells 
Factor: Number of confirmed unwells 

Source Document : Problem Referral & Case-monitoring Sheet 

Screening Sheet 

Comment: Those cases with more than one problem (more than 
one problem sheet) found at screening and confirmed (multiple 
problem case). 



(T 



65 



Factor : Number of case completions (resolutions) 
Source Document : Problem Referral and Case-monitoring Sheet 
Comment : A case will be considered completed when aVI^ 
problems identified with a case have been resolved as reflected 
in Item 7 of the lower third of the Problem Referral & Case- 
monitoring Sheet, e.g.. 

Current Status of Case (if multiple problems identified) 

a. Problems Identified (problem sheet originated) 

(circle one) 1 ® 3 4 5 

b. Problems resolved or terminated as of date this 
form completed 

(circle one) ^ ® 3 4 5 

Rate of Case Completions of Shows at Screening 

Factor : Number of shows for screening 

Source Document : Screening sheet 

Comment : Those identified as "shows for screening" in 
case-finding subsystem (a screening sheet reflecting Medicaid 
number, name, age, and any one or more additional screening step 
entries in the columns. Medical History, Tests & Measurements, 
and Physical Examination). 

Factor : Number of screening completions 

Source Document : Screening Sheet 

Comment: A screen will be considered completed when Item 
9 of the Screening Sheet * "Screening now complete?", has been 
checked "Yes" (Yes [/]) and the adjoining "Screening sequence" 
has been identified by (/) as an "Original EPSDT". 



66 



Rate of Rescreen Completions of Eligibles for Rescreen 
Factor : Number of eligibles for rescreens. 
Source Document : 

(1) List of Medicaid eligibles 

(2) State or Community Rescreening Sequence Schedule 

(3) Case monitor records of initial EPSDT screens 

and previous rescreens 

Comment : Eligibles for rescreen are determined by the case 
worker based upon current Medicaid eligibility of children who, 
by his/her records had had previous screening or rescreening 
and who, by tKe applicable rescreening schedule, are now due 
for an additional rescreen sequence. In an ADP system the 
computer could provide a list of eligibles for rescreen by 
month or quarter, based upon correlating a rescreening sequence 
schedule [by time and age) with stored data of previous screens 
by name and I.D. number and with new list of Medicaid eligibles. 

Factor : Number of rescreen completions 

Source Document : Screening Sheet 

Comment : A rescreen will be considered complete when Item 
9 of the Screening Sheet, "Screening now complete?", has been 
checked "Yes" (Yes [/]) and the adjoining "Screening Sequence" 
has been identified by (/) as a "Periodic Rescreen". 

(If cohort system not employed) 

If the cohort concept is not used in this project, the 
rates of case completions will be based upon the number of 
confirmed unwells (children with one or more confirmed problem 
sheets) identified during the past six months , and the number of 



67 



these who had a1 1 their identified problems resolved in this 
period. 

If, for example, during the six months prior to the last 
day of the report period, 1000 children were identified with 
one or more confirmed problems and during this period 500 of 
these children had all their problems resolved, the rate of case 
completion of confirmed unwell s would be 50% (at the end of six 
months). 

A second and third factor reflecting the rate of case 
completions of confirmed unwells at the end of 12 and 18 months 
will also be utilized. 

These factors will be based upon samples of children who 
were identified with one or more confirmed problems in the 
period 7-12 months and 13-18 months prior to the last 
day of the report period and are still active and/or eligible 
in the project. 

One hundred children will be identified in each category and 
these will be surveyed to ascertain the number who had their case 
resolved during the ensuing period. If, for example, 75 of the 
100 representing the 7-12 month period and 95 of the 100 
representing the 13 - 18. month period had reached resolution by 
the last date of the report, the period rates would be 75% and 
95% respectively, at average cost per case completed identified 
with these respective time frames. 
Cost Measurement 

(Reference Section III - Common Data Base, C. - Cost Data) 




( 



68 



EXAMPLE : Cohort moving through the five subsystems in time 
Subsystem: Casefinding 

At time one, say January 1, 800 Medicaid eligibles are identified as the 
target population. The first subsystem is called case-finding. The outreach 
effort produced 120 shows at the screening site. 

Of the 120 shows for screening, only 100 had completed the screen. During 
the three months between quarterly reports, eligibility status had changed on 
75 children. Fifty are no longer eligible and 25 new cases are added to the 
eligibility list. Of the 50 dropped, 30 Showed for screen and had a completed 
screen, and of the 25 newly eligible, 10 showed for screen and had a completed 
screen. The penetration rate is based on the total number who showed for 
screen, which is 120. However, the population on April 1 is: 

April 1 eligible population = January 1 population - no longer eligible + 

new eligibles 
=800-50+25 
= 775 

Since 30 of the children who were no longer eligibles showed for screen, they 
are included in calculating the penetration rate. The 30 are added to both 
components of the penetration rate formula. Hence, 

# of "shows" # of "shows" of # of "shows" of 
Penetration Rate = of eligibles + dim not eligible + newly eligible 

# currently eligible + # of "shows" of now not eligible 

= 80+30+10 
775 + 30 

= 15% 

Subsystem: Screening 

Of the 100 with c ompleted screens J 80 had suspected abnormal checked on 
^For these computations it is assumed that there is one problem per child. 



III 




69 



the screening form. The remaining 20 were marked suspected normal. 

Where quality control exists, a re-examination would be conducted 
on 15% of those screened. Therefore, 15 children would be rescreened. 
Since each screen results in 67 possible findings, normal or abnormal, 
there are a total of 15 x 67 = 1,005 findings. If rescreening confirms 
that 100 of the 105 abnormal findings, and 850 of the 900 normal find- 
ings, the rate of confirmed findings is: 

# of confirmed findings 
Rate of confirmed findings = # of original findings 

= 950 
1005 

= 95% 

Those children falsely declared normal or abnormal would return 
to the appropriate spot in the diagnosis subsystem. 

Returning to the 80 with suspected abnormal and 20 with suspected normal, 
the 20 screened cases that have no abnormal findings are declared well and 
placed in the case monitoring subsystem. Of these 20, five children are no 
longer Medicaid eligible. Of the 80 with suspected abnormalities, 10 are no 
longer Medicaid eligible, but five of the cases entered the diagnosis subsystem 
before losing eligibility. Thus, 75 children are referred to a health provider. 
(Although each child can have a multiplicity of problems, this example will 
consider only one child/one abnormality/one problem. However, the 75 could be 
increased to reflect the number of problem sheets initiated per child. 
Subsystem: Diagnosis and Treatment 

After the 75 cases are diagnosed by a health provider, only 50 have a 
detected problem. Therefore: 

# detected problems 

Rate of abnormalities confirmed = # suspected abnormalities 

= 50 
75 

= 67% 



(J 



if 



70 



After diagnosis, 25 of the 75 cases have no detected problems and are 
placed in the case monitoring subsystem. The 50 cases having detected problems 
are now in the treatment subsystem. 

Although eligibility status again changes, children already in the treatment 
subsystem are not dropped until four months after their first treatment. This 
should give enough time for a quarterly report stating the rates of conversion 
from unwell to well or to otherwise resolved, or to needs continuing treatment. 

On July 1 the 50 cases with detected problems have been treated. Thirty 
are now well, 10 are otherwise resolved, five need continuing treatment, and 
five did not show for appointments--lost to follow-up. 

Hence, rates of conversions are: 

unwell to well = # well 

# with detected problems 

= 30 
50 

= 60% 

unwell to otherwise resolved = # otherwise resolved 

# with detected problems 



= 10 
50 

= 20% 



unwell to continuing treatment = # needing continuing treatment 

# with detected problems 



= 5_ 
50 



= 10% 

Subsystem: Case-Monitoring 

On July 1 the rates for the case-monitoring subsystem are established. 
There are three to be considered. Case completion of the detected problems. 



( 



(f 



71 



completed screens based on the number that show for screening and cases kept in 

the system of the number screened. 

Since the 100 originally screened had 50 detected problems and 40 cases 

were converted to well or otherwise resolved, the case completion rate is: 

Rate of completion = # of cases converted to well or resolved 

# with detected problems 

= 40 
50 

= 80% 

Recall that 120 children showed for screening, but only 100 of these com- 
pleted the screening steps. 

Rate of completed screens = # of completed screens 

# of shows for screen 

= 100 
120 

= 83% 

Another aspect of the case-monitoring subsystem is the rate measuring the 
number kept in the system. While in the treatment phase, five children did not 
keep appointments and were lost to follow-up. Also five of the children who 
were screened lost eligibility before entering the diagnosis subsystem. Hence, 
the total number screened is only 95. 

Therefore, the rate is: 

Retention rate = # kept in system 

# screened 

= # converted to well continuing well from well in 
or resolved + treatment + screening + diagnosis 

# screened 

= 40+5+20+25 
95 

= 95% 



d' 



1 



72 



Summary of Cohort 1 Numbers 

Case Finding 



"Shows" of eligibles 80 

"Shows" of now not eligible 30 

"Shows" of newly eligible 10 

Currently eligible 775 

Diagnosis and Treatment 

Suspected abnormalities 75 

Detected problems 50 

Unwell to well 30 

Unwell to otherwise resolved 10 

Unwell to continuing treatment 5 

Case-Monitoring 

Completed screen 100 

Shows for screen 120 

Converted to well or resolved 40 

Well from screening 20 

Well from diagnosis 25 



Summary of Rates for Cohort 1 

Case Finding 



Penetration 15% 

Screening 

Confirmed Findings 95% 

Diagnosis and Treatment 

Abnormalities confirmed 67% 

Unwell to well . . 60% 

Unwell to otherwise resolved 20% 

Unwell to continuing treatment 10% 

Case-Monitoring 

Case completion 80% 

Completed screens 83% 

Retention 95% 



/I 




( 



TABLES 1 - 5 

Four Cohorts Moving Through the Five Subsystems in Time 

The following tables illustrate the rates obtained in evaluating four 
cohorts moving through the five subsystems. The penetration rate and the 
diagnosis and treatment rates are given from both the perspective of an 
individual cohort and the cohorts combined. 

Tables one and three give hypothetical numbers that are used in 
computing the rates in tables two, four and five. The preceeding example 
presents the computational formulas used to get the rates for the five 
subsystems. 



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75 



Table 2 
Penetration Rates 
(Using the numbers from Table 1) 

Single cohort rate Combined cohort rate 

Jan. 1 - March 31 120 ( 80 + 30 + lO )** 

805 = 15% 775 +30 = 15% 



Apr. 1 - June 30 100 90 +(85 + 5 + 10 ) 



685^= 15% 775 + 5 = 24% 



July 1 - Sept. 30 IJO 90 + 95 +(95 +0+15 ) 

590 = 19% 785 +0 

Oct. 1 - Dec. 31 _95 90 + 95 + 110 +(84 +5+6 ) 

490 = 19% 780+5 = 50% 



*Note: Denominator of single cohort = Base population - No. of currently eligible 
who have showed for screening in preceeding cohorts 

Denominator of combined cohort rate = Base population + No. of shows for 
screen now not eligible 

**Numbers in parenthesis in third column represents the single cohort in the 
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79 



VII. STANDARD AND SPECIAL SUB-STUDIES OF PROGRAM IMPACT 

Two types of special studies of program impact will be routinely 
accomplished. These are indicated below. Other special studies will be 
conducted as necessary to fulfill informational needs of the demonstration 
activity and the Institute. The purpose, rationale, methodology, and end 
product of each of these sub-studies are contained in related annexes, as 
indicated. 

A. Standard Studies 

The demonstration evaluation process will include certain standard 
sub-studies to assess the impact of EPSDT on the target area and popu- 
lation. The data to conduct these studies is programmed for collection 
in the model forms contained in Section IX. These standard studies 
will measure change in the target population over time in the following 
conditions or areas: 

1. The general status of child health through means of a 
healthiness rating (Annex A) 

2. Immunization status (Annex B) 

3. Seriousness and type disease/injury condition (Annex C) 

4. Utilization of various community health services (Annex D) 

5. Medicaid costs (Annex E) (Supplementary Medicaid data required ) 

B. Special Studies 

Certain special studies will be conducted as needs indicate. 
They will require special data. Examples of several contemplated 
which will measure changes in specific areas or groups over time are: 

1. Recipient attitude toward the program (Annex F) 

2. Staff attitude toward the program (Annex G) 

3. Provider attitude toward the program (Annex H) 



80 



ANNEX VII-A 



Standard Healthiness Rating Study 



Purpose : To provide, both individually and collectively, a measure of the 
improvement in child health resulting from the EPSDT program. 

Rationale : The screener, after having reviewed test results, child and 
family health history, and performed a physical examination, is in position 
to have a reasonably valid opinion of the child's health and express this 
as a numerical healthiness rating. Previous studies in the Barrio Child 
Health Care Center in San Antonio have shown that this rating is possible and 
can crudely summarize a child's health status. 

Methodology : 

1. This rating is discussed in detail in the narrative relating to the 
healthiness ratings on the Screening Sheet (Chapter IX). (The 
screener rates each child on a scale of 1 to 9 continuum, where 1 is 
extremely sick and 9 is extremely healthy.) 

2. Screeners will assess the rating and record it in the appropriate section 
of the screening sheet. It will be subsequently recorded on each periodic 
rescreen. 

3. The rating will be compared for each periodic screen. For each initial 
rating, the average units of healthiness will be computed. The null 
hypothesis of no significant improvement will be tested with a paired 
comparison t-test. By the end of the third year of the demonstration, 
there will be enough children rated twice, and in young children, three 
or four times, to allow meaningful comparisons by the use of multiple 
regression techniques of changed ratings by age, sex, race, previous 
utilization of health services. 

End Product : A sumnary (in the form of a multiple regression equation) of 
changed healthiness according to age, sex, race, previous utilization of 
health services, initial rating, and "correction of problem" status. 



} 



81 



ANNEX VII-B 



Standard Study of Immunization Level Changes 



Purpose : To compare the percentage of children who were "current for their 
age" in the DTP, Oral Polio, and Measles, Mumps, and Rubella immunization 
status prior to the screening to those after screening. 

Rationale : Immunization status is an important indicator of the utiliza- 
tion of preventive health services, and measures the current preventive 
healthiness of the population. 

Methodology : A check of the irranunization status is a part of each screening 
exam. Initially, the staff will record the immunization record on the 
Immunization Annex to the Screening Sheet along with an indication of the 
number of contacts (dates additional shots required) necessary to bring the 
child's status to "current" as a measure of projected workload. Then, at 
the time of each periodic screen, the staff will record the current and 
projected status of immunizations. The analysis will include an enumeration 
by age, sex, race, and quarter, of the immunization status of the children 
being initially screened and those being rescreened. For those being 
rescreened, there will be an enumeration of percentage points change in 
immunization level since the previous screen and the first screen. This 
percentage will be stated in terms of the 95% confidence intervals. 

End Product : A statement of the changes in immunization levels resulting 
from the EPSDT program. 



82 



ANNEX VII- C 



Standard Study of the Types and Seriousness of 
Conditions Found, Followed up, and Resolved 



Purpose : To illustrate the existing current health needs in the target 
population and to measure the extent to which the long term goal has been 
met in terms of conditions resolved. 

Rationale : The conditions found, if described in enough detail (in terms 
of type of problem, severity) will indicate unmet health needs and levels 
of previous care. 

The extent of correction of various types reflects the adequacy of the 
diagnosis and treatment linkages and case management as well as a measure 
of program impact. 

Methodology : When a problem worth referring is detected in screening, a 
problem sheet is completed. The staff will indicate the nature of the 
problem. The evaluator will code this into one of 38 groupings of ICDA 
(International Classification of Disease) categories used most frequently 
in other child health program studies. When a problem sheet is completed 
by the diagnostician, the finding will be indicated, as well as the 
problem severity (on a scale of 1 - 5, indicating mild, moderate, or severe) 
The screener records whether or not the problem was previously under care. 

The problems found will be enumerated according to age, sex, and race a 
compared with findings in x)ther EPSDT demonstrations. 

The returned problem sheets and follow-up statements will be processed 
by the evaluators to determine what problems are not getting resolved; along 
with the reasons. 

End Product : A listing of conditions found and resolved, by age, sex, race, 
and quarter. 



{ 



83 



ANNEX VII-D 



Standard Study of Patient Indicated Ut i 1 i za t i on 



Purpose : To assess the previous utilization of health services and well- 
child care, based on the patient's own description. 

Rationale : One measure of the impact (input oriented) is to show the extent 
to which children in the population that got screened were recipients of 
preventive health services. If the group that gets screened are heavy 
utilizers of the system and are already receiving screening exams, then 
this program may be a duplication of services. 

Methodology : Each child's history is recorded by the staff at the time 
of screening. On the screening sheet there are two summary sections in 
which the staff, after discussion with the patient, summarizes the number 
of visits to various health providers in the past twelve months and checks 
if the child had a vision test, hearing test, or physical exam, generally 
in the previous year. 

Confidence intervals will be stated for the average number of visits 
to various providers according to age, sex, race, number of problems 
found in screening, and healthiness rating. Differences between these 
groups will be assessed by t-tests, n-dimensional Analysis of Variance and 
multiple regression. 

End Product : A statement about the level of previous utilization of various 
health services and the relationships of that utilization to screening 
findings. The Texas HSRI hypothesis that the findings are greater in children 
who have not had previous complete physical exams (including vision and 
hearing tests) will be tested in this population. 



84 



ANNEX VII-E 



Standard Health Services Utilization Changes Study - Medicaid Records 

Purpose : To determine the effect of EPSDT project on Medicaid paid health 
services. 

Rationale : An effective EPSDT program may be expected to: 

a. Increase preventive health visits to private physicians. 

b. Increase short run health visits for those declared unwell, but decrease 
long run health visits for crisis care. 

c. Decrease short run health visits for care in those children found to be 
normal . 

Methodology : A random sample of children screened by the project will be 
selected by the evaluators. The name and Medicaid number will be submitted 
to the fiscal intermediary for the State, quarterly. A copy of the com- 
puterized beneficiary profile will be requested for each child. The number 
of visits to health care providers that are shown or the profile will be 
tabulated by type of provider and reason for visit (check-up versus sick 
visit) for the period 12 m.onths prior to screening and three and six months 
after the date of screening for the cohort of children screened in a given 
quarter. Eventually data will be available covering a time period, 3, 6, 
12, and 24 months after screening. 

The change in the number cf visits to each type of provider and corres- 
ponding costs to Medicaid will be correlated to the types of problems found 
and resolution status. 

In addition, an equal random sample of children in the community who 
were not screened by the program will be requested and coded. The change in 
utilization of those screened, compared to the change for those in the non- 
screened sample should include the true total programmatic effect on utilization. 

A small pilot sample will be done initially to test the system of re- 
trieving data. This will also aid in developing the code sheet for the study. 



End Product : Statement of the programmatic effect of EPSDT on the utilization 
of health services, by type of provider and type of service. 



ri 



( 



( 



85 



ANNEX VII-F 



Special Patient Attitude Study 



Purpose : To determine the appropriateness of care delivered under the 
EPSDT program and the response of patients to this type of preventive care. 
To determine the knowledge of hygiene and preventive care. 

Rationale : If the mother did not understand what was done to her child at 
screening, the meaning of the results, and shows positive attitude toward the 
clinic, then even though the services are currently cost effective, they will 
not reach a significant part of the community over the longrun period of time. 

Methodology : A questionnaire will be administered through personal interview 
in the homes of 200 families in each target area, chosen randomly from those 
screened. In addition, fifty no-shows will be interviewed to determine the 
reasons for not utilizing the clinic services. 

The interview schedule has not yet been developed but will be modeled 
after the schedule currently being used in the Barrio Comprehensive Child 
Health Care Center in San Antonio. The results will be coded and analyzed 
with cross tabulations. 



End Product : A statement of patient- viewed positive and negative comments 
about the screening program and its operation. 



86 



ANNEX VII-G 



Special Staff Attitude Survey and Organizational Analysis 



Purpose : To determine the workability of the EPSDT model with respect to 
long-term continuity from the staff's point of view. 

Rationale : If the staff is not happy with the project and their jobs, then 
the project will not be performing to capacity. In addition, if the staff 
does not understand and believe the project goals, then performance may be 
less than expected. 

Methodology : The instrument, yet to be developed, will include the job 
satisfaction index. Also included will be open-ended questions about 
changes that could be made to improve the operations. 

End Product : A statement of staff attitude toward EPSDT and the project 
which could indicate successes as well as potential employee problems in 
future EPSDT programs. 



f 



(I 



( 



87 



ANNEX VII-H 



Special Community Linkages Study 



Purpose : To determine the extent to which linkages have been achieved with 
the public and private health agencies in the community. 

Rationale : Linkages are necessary to achieve a high rate of resolved condi- 
tions and to assure continuity of care during the time when the child is 
between EPSDT screenings. 

Methodology : 

1. Using the computerized research results, tabulate the number and types of 
providers to whom children were referred and the number from whom problem 
sheets were returned. 

2. Through a mail survey to providers having received five or more referrals 
from the EPSDT program, ask each provider about their attitudes toward 
the screening program, the client's apparent knowledge of the problems 
sent to them and the helpfulness of the health department in ensuring 
continuity of care. This questionnaire is to be developed later and 
will be given twice--one at the end of the first year of the project 

and again several months before the end of the project. 

End Product : A statement of community health care providers about the 
efficiency of the screening project. 




I 



88 



VIII. STANDARD OPERATIONAL AND EVALUATION REPORT SYSTEM 

A standard system of reports is established to provide guidance for 
both demonstration and evaluation groups in terms of reporting evaluative 
and operational data at specific time reference points, and to give emphasis 
to specific facets of the demonstration activities. The "operational report" 
(progress report) is prepared and submitted by each project directly to ORD/SRS 
whereas the "evaluation report" is prepared and submitted to ORD/SRS by the 
Health Services Research Institute (with copies to the respective projects). 

The data resulting from the demonstration and its subsequent analysis 
are the primary purposes for the investment of research and development 
funds in demonstration projects. The validity of the results and their 
probability for transferability to other similar environments are literally 
totally dependent upon the accuracy of the data, which, in turn, is 
dependent upon the preciseness and completeness of forms utilized at the 
project level . The accuracy, completeness and timeliness of all data 
collection forms is, therefore, a primary concern of all personnel involved 
in the EPSDT demonstrations. 

Two categories of reports will be utilized, i.e., (1) operational and 
(2) evaluative. 

A. Operational Reports (Progress reports) 
1 . General 

The operational report is prescribed by SRS and is of primary 
interest to that agency. The purpose of the report is to inform the 
grantor (SRS) of the status of funds and project mile- 
stones in time. Problems inhibiting the attainment of time goals, 
etc., should be identified and discussed, with recommendations for 



89 



resolution or change. 

The focus of this report is administrative/operational - -not 
research results or evaluation. 

The report will be prepared by the on-site Project Director and 
forwarded quarterly directly to SRS, with an information copy to 
the Institute in accordance with the following schedule: 
Period covered Date due at SRS 

July 1 - September 30 October 15 

October 1 - December 31 January 15 

January 1 - March 31 April 15 

April 1 - June 30 July 15 

The operational report should be brief and specific. As a 
general guide, it should rarely exceed three or four pages. 

The content and format of the report will be as directed by 
SRS/ORD, in separate instructions to the project. 

Evaluation Reports 
1 . General 

The evaluation report is a reflection of the analysis of the 
data from the projects as related to the factors and hypotheses 
being tested and their associated costs. Generally, the analysis 
of the data collected to answer the questions hypothesized by the 
specific demonstration projects will take the form of graphs and 
charts based on proportions. The specific experimental designs 
dictated by rigorous controls set on certain variables relating 



c 



90 



to specific testable hypotheses will be analyzed by theoretical 
statistical procedures (i.e., analysis of variance, discrim- 
inant analysis, regression analysis, etc.) These analytical 
displays will pertain to both the single demonstration and, when 
appropriate and appl i cable, to a comparison with other demonstrations. 

When demonstration projects are organized to function statis- 
tically and experimentally as several independent and identifiable 
sectors, in which varying factors may be tested simultaneously, 
data and displays may be reported and analyzed by sector. As an 
illustration, page 9 of the example of a research format in 
Chapter XIII shows different variables being tested simultaneously 
in six sub-divisions (sectors) of a hypothetical demonstration 
project. It also indicates variations in the time periods for 
testing certain of the variables. Some are projected for testing 
for three months, others for 14 months, others for 30 months, etc. 
In these instances, the data (and related analysis) are not 
reflecting the overall project (demonstration performance) but 
only the performance of the variable in those specific sectors 
for specific periods of time. The intent will be to compare the 
results of testing the same variable in similar environments in 
other sectors of other demonstrations to determine the consistency 
of the technique (variable) in other similar environments. 

This research schema of testing the same variables in several 



CI 



91 



sites is reflected in the chart (page 220) in the example in 
Chapter XII. 

Listed below are the more or less standard areas of analysis 
and evaluation as they relate to the testable hypotheses previously 
identified by subsystem as well as those other areas for analysis 
identified in Chapter VII (Special and Standard Sub-studies of 
Program Impact). Following in this chapter are also illustrations 
(example charts and tables) of the manner in which some of the 
data may be displayed in the Evaluation Reports, as well as an 
explanation of the means by which the data will be gathered to 
constitute the basis for the statistical evaluation (source forms, 
numbers [sample sizes], time periods covered, etc.). 

In some instances, and where appropriate, the data will 
reflect quarterly analysis (quarterly reference points), in 
other instances will be semi-annually or annually, or cumulative 
from point of project origin (Phase I) to the end of the period 
being reported upon. In other instances, data will be analyzed 
on a "spot" basis (one-time; non-continuous). 

In this context, each of the semi-annual (routine periodicity) 
Evaluation Reports will not necessarily reflect analysis of the 
same data or, therefore, contain the same charts and tables. 

Data Displays - Areas of Analysis 

#1 - Performance Profile - All subsystems - Dollar costs per rate of performance 
by subsystem - Status at end of the report period 



(if 

r 

I 



Rate of Shows for Screening 

a. Ages 0-5 

b. Ages 6-12 

c. Ages 13 - 18 

d. Ages 19-20 



(Continued on page 95. Pages 93 and 94 missing because of mater 
deleted from this chapter after pages were numbered and forms 
printed--in order to save time.) 



9 



95 



#3 - Rate of Confirmed Findings 

a. Well (also reveals rates of false negatives) 

b. Unwell (also reveals rates of false positives) 

#4 - Rate of Conversions to Well 

a. Acute conditions 

b. Chronic conditions 

#5 - Rate of Case Completions - All conditions - at the end of 6, 12 and 18 
months respectively 

a. Of confirmed unwells (l)Problem completions & (2) case completions 

b. Of shows for screening (Completed screens) 

c. Of eligibles for rescreen (Rescreens completed) 

#6 - Healthiness rating (Percent in three categories of healthiness) 
#7 - Immunization status (Percent current) 

#8 - Severity of Conditions Found - all conditions (Mild, moderate, severe) 

#9 - Health Problems identified as related to previous preventive and acute 
encounters in the 12 months prior to screening 

#10 - Medicaid Costs before and after screening (12 months before and 0-12 months 
and 13-24 months after); specific conditions 

#11 - Child Health Services utilization by type before and after screening (12 
months before and 0-12 and 13-24 months after) 

2. Periodicity, Due Dates and Processing Schedule 

The evaluation reports will be prepared on a semi-annual basis 
according to the following schedule. 

Period Covered Date Completed Date Due at SRS 

July 1 - December 31 March 31 April 15 

January 1 - June 30 September 30 October 15 

The processing of data and the preparation of the evaluation 
report will be in accordance with the following schedule of events 
following the end of the report period (period covered). 



96 



Days After End of 
Report Period 

End of Report * 
Period 

+ 7 days 



+ 10 days 
+ 20 days 

+ 35 days 

+ 36 days 

+ 40 days 
+ 55 days 

+ 60 days 
+ 63 days 
+75 days 

+ 90 days 



+ 105 days 



Action 

Demo - Begin assemblying all residual input forms 
pertaining to the completed quarter. 

Demo - Close out appropriate data input forms pertaining 
to the report period and foward to the Institute with 
notification that this represents the close-out for 
the report period.** 

Institute - Final input forms arrive at Institute. 

Institute - All input data for report period coded 
and punched. 

Institute - Data processed, print-outs and displays 
and/or tables completed. 

Institute - Print-outs and/or displays mailed to 
demonstration. 

Demo - Print-outs and displays received. 

Demo - Review data, analyze, prepare any pertinent 
comments relating to print-out or display. 

Demo - Dispatch commentary on data to the Institute. 

Institute - Commentary arrives at Institute. 

Institute - Review project comments, analyze data and 
prepare letter of transmittal for the report, in- 
cluding a summary of significant findings. 

Institute - Dispatch to SRS letter of transmittal, 
summary of significant findings and individual 
demonstration reports. Copies will also be mailed 
to the respective demonstrations. 

SRS - Institute evaluation report arrives at SRS. 



*Either December 31 or June 30 

**A11 remaining forms in the project representing incomplete actions at 
this point in time will be picked up in the data for the next evaluation report. 



f 



Days After End of 
■ Report Period 



End of Report * 
Period 

+ 7 days 

+ 10 days 
+ 20 days 

+ 35 days 

+ 36 days 

+ 40 days 
+ 55 days 

+ 60 days 
+ 63 days 
+ 75 days 

+ 90 days 



Demo - B 
perta 

Demo - C 
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97 



Data Display #1 - Performance Profile - A11 Subsystems 

This is the overall profile of performance in all of the EPSDT subsystems 
in the project during this report period. The formulas for computing rates 
are contained in Chapter VI of this Handbook, and delineation of cost data in 
Chapter III. Detailed analysis of the components of this display are contained 
in following displays. When appropriate, this display may relate to specific 
sectors in the demonstration or may reflect only certain elements for consid- 
eration, or may not be utilized since the data is reported in other forms in 
other displays. 

An example of this chart representative of a situation in a demonstration 
follows the display format . 



98 



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Data Display #11 - Rate of Show (fay .quar ter) Ages 0-5. 6-12, 13-18 and 19-20 

This is a detailed display on the case-finding subsystem reflecting 
the rate of show by quarter (penetration rate) from point of project origin 
(pre-demonstration rate - Phase I) to end of the period being reported upon. A 
base rate and cost per show is established (Phase I) and subsequently this and 
additional quarters are impacted by new factors being tested. The impact of 
each new factor is indicated on the rate continuum display. The factor being 
tested in each period is indicated in the lower half of the display with an 
indication of the gross cost to this subsystem to fund the "factor" and the 
resultant "cost per show". 

Age groups 0-5, 6-12, 13-18, and 19-20 are reported separately. This is neces- 
sary to reflect the differences in costs and rates of outreach efforts in those juris- 
dictions where the EPSDT effort is school oriented for ages 6-18 (or screening 
is a mandatory prerequisite to school admission) and the pre- and post school 
groups are more difficult to "penetrate". The report is reflecting the number 
of eligible children that have "shown for screen". 

If the cohort concept, as defined in Chapter VI of this Handbook, is not 
used in this project the rates of shows will be based upon the number of children 
that "show for screen" of a list of eligibles as of the last day of the report 
period. If, for example, there are 600 children not previously screened^ 
still active and eligible in the project as of Decemoer 31, 1974 and 100 
of these children have shown for screen during the quarter, the 
rate of penetration is 17% in that quarter (with those techniques) and the costs 
for outreach (case-finding) must relate to the same time period to reflect the 
"cost per show" at this rate. Report separately those children who "showed for 
screen" during the period but were not on the list of eligibles as of the last 
■'•In some earlier quarter 



4 




101 



day of the report period. This figure will be utilized in conjunction with those 

el igible as of the last day of the report period that showed for screen to 

compute a "cost per screen" in this subsystem for the period that is independent 

of the rate. For example, in addition to the 100 "shows for screen" that are 

still active and eligible on the last day of the report period, 25 others 

"showed for screen" during the quarter but are not active or eligible on the 

last day of the report period (moved from area or Medicaid eligibility expired 

during the quarter), these would be totaled (100 + 25 = 125) and utilized to 

compute the actual average cost per show for the period (" cost per show " = 

125 

average cost per show). This method is utilized to avoid the more complex 
procedure of attempting to keep track of additions and deletions to the base 
population (the eligibles) during the report period and the results of pene- 
tration efforts in these categories (additions and deletions) in order to 
achieve a "pure" rate and average cost. 

An example of this chart representative of a situation in a demonstration 
follows the display format. 

Data Display #IIA - Rate of Shows by Quarter - Ages 0-5 
(as indicated above) 



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104 



Data Display #111 - Rate of Confirmed Findings (Well and Unwell) 

This is a detailed display on the screening subsystem which is quality 
control focused, reflecting the rate of confirmed findings of well (no problem 
sheet initiated) and unwell (problem sheet initiated) per quarter from point 
of project origin to end of quarter being reported upon. Unless there is a 
quality control procedure as indicated in Chapter VI, B, 2 of this Handbook, 
this section can only report on confirmed unwell s--true positives. If this 
condition prevails, the display should be modified to so reflect and the 
narrative concerning the display should identify the reasons there are no 
"true negative" quality control procedures. 

A base rate and cost per screen is established (Phase I) and subsequently 
this and additional quarter rates and costs are impacted by new factors being 
tested. The impact of each new factor is indicated on the rate continuum 
display. The factor being tested in that quarter is indicated in the lower 
half of the display with an indicator of the gross cost to this subsystem to 
fund the "factor" and the resultant "cost per show". 

An example of this chart, representative of a situation in a demonstration , 
follows the display format . 

If the cohort concept fes defined in Chapter VI of this Handbook) is hot used 
in this project, the rates of confirmed findings (unwell) will be based upon the 
number of conditions diagnosed (referred and diagnosed) during the quarter, and 
the numbers of these that had an unwell condition confirmed. If, for example, 
210 problem sheets were returned during the three months of the report period 
and 190 were confirmed as problems, the rate of confirmed findings (unwell) would 
be 90% (190 V 210 = 90%) at a specific average cost per screen (the cost of 
operating the screening subsystem for the period). 



# 



( 

r 



105 



If a quality control procedure is in effect to measure false negatives, 
the rate of confirmed findings (well) will be based upon the number of "well" 
children found and confirmed as "well" by the quality control procedure 
(professional rescreen) during the period. If, for example, there are 400 
children found "well" by the screening procedure during the quarter and the 
quality control rescreen of a 15% sample of these(60) confirms 50 as well, 
the rate of confirmed findings of well would be (50 ^ 60 = 83%). 

The overall rate of confirmed findings (well and unwell) would be 86% 
based upon (210 + 400 =) 610 total findings of unwell and well, and 
(190 + 332 [400 X 83%^= 332] =) 522 confirmed findings (522 v 610 = 86%). 
This rate will be used in conjunction with costs to operate the subsystem 
during the report period in terms of the "average cost per screen". 

*Appli cation of the sample rate (83%) to the total of wells. 



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108 



Data Display #IV - Rate of Conversions - Chronic Conditions - 

This is a detailed display on the diagnosis and treatment subsystems which 
is outcome focused, reflecting the rate of conversions to well or inactive of 
children originally found with active chronic conditions (and confirmed) and 
subsequently, through a therapeutic regimen, converted to a status of well or 
inactive (as distinguished from "not cured but maximum benefit from treatment 
achieved" or any category of "not resolved"). 

A base rate and cost per conversion is established (Phase I) and subse- 
quently this and additional quarter rates and costs are impacted by new factors 
being tested. The impact of each new factor is indicated on the rate continuum 
display. The factor being tested in that quarter is indicated in the lower half 
of the display with an indication of the gross cost to this subsystem to fund the 
"factor" and the resultant "cost per conversion". 

The example of Data Display #11 and #111 should apply to this display. 

If the cohort concept is not used in this project the rates of conversion 
to well or inactive will be based upon the number of problem sheets pertaining to 
chronic condtions that are returned by practitioners during the six months prior 
to the end of the report period and the number of these that had the problem 
resolved during this period. 

If, for example, during the six months prior to the end of the report 
period, 180 problem sheets pertaining to chronic conditions are returned from 
practitioners, of which 100 achieve problem resolution and 25 of these indicate 
the resolution as [7] Treatment plan completed, now cured or inactive (Item 2d, 
Case Monitor Section, Problem Referral and Case-monitoring Sheet), the rate of 
conversions-'Chronic conditions, unwell converted to well or inactive is 25% 
(25 T 100) for this six month period at a specific average cost per case (chronic 



109 



condition) for diagnosis and treatment.* 

A second and third factor will also be used reflecting the rate of con- 
version to well of chronic conditons by the end of 12 and 18 months, respectively. 
These will be based upon samples of problem sheets which identified chronic 
problems in the period 7-12 and 13-18 months prior to the last day of the 
report period and are still active or eligible in the project. 

One hundred problem sheets will be identified in each category (of time) 
and these will be surveyed to ascertain the number resolved during the ensuing 
period. If, for example, 75 of the 100 representing this 7-12 month period 
and 95 of the 100 representing the 13-18 period had reached resolution by the 
last date of the current report period, the rates would be 75% and 95% 
respectively, at average cost for chronic problems completed identified with 
these respective time period. 



*It is assumed that the remaining 75 are resolved as [7] Not cured, but 
maximum improvement achieved (condition still active). 



110 



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Data Display #V - Rate of Case Completions - of Confirmed Unwells 

This is a detailed display on the case-monitoring subsystem reflecting the 
rate of c ase completions for confirmed unwells by quarter from point of project 
origin (pre-demonstration rate - Phase I) to the end of the quarter being reported 
upon. A base rate and cost per case completion is established (Phase I) and 
subsequently this and additional quarter rates and costs are impacted by new 
factors being tested. The impact of each new factor is indicated on the rate 
continuum display. The factor being tested in that quarter is indicated in the 
lower half of the display with an indication of the gross cost to this subsystem 
to fund the "factor" and the resultant "cost per case completed". Case completions 
and problem completions of "confirmed unwells", "shows for screening" and 
"rescreens" are reported separately. 

Case completion^ in this context, relates to the resolution in some form 
of all problems relating to a specific child (where multiple problems have 
been identified ) [whereas rate of conversions (diagnosis and treatment subsystem) 
related to individual problems being resolved]. 

Additionally, case completion of confirmed unwells by significant problem 
categories (frequency and severity) is programmed and each will be included in 
appropriate reports as separate displays as indicated (see model data display #5, 
following). [These analyses, of course, will relate to completion of the 
specific problem involved as distinct from cases which is the criteria in the 
broad concept of "case completions of confirmed unwells",] 

If the cohort concept (as defined in Chaoter VI of this Handbook, is not used 
in this project the rates of case completions will be based upon the number of 



112 



confirmed unwells (children with one or more confirmed problem sheets) identified 
during the past six months , and the number of these who had all their identified 
problems resolved in this period. 

If, for example, during the six months prior to the last day of the report 
period, 1000 children were identified with one or more confirmed problems and 
during this period 500 of these children had all their problems resolved, the rate 
of case completion of confirmed unwells would be 50% (at the end of six months). 
This will be reflected as one distinct line on the chart. 

A second and third factor reflecting the rate of case completions of confirmed 
unwells at the end of 12 and 18 months will also be utilized and displayed as two 
other distinct lines on the chart. 

These factors will be based upon samples of children who were identified with 
one or more confirmed problems in the period 7-12 months and 13-18 months prior to 
the last day of the report period and are still active and/or eligible in the 
project. 

One hundred children will be identified in each category and these will be 
surveyed to ascertain the number who had their case resolved during the ensuing 
period. If, for example, 75 of the hundred representing the 7-12 month period 
and 95 of the hundred representing the 13-18 month period had reached resolution 
by the last date of the report, the period rates would be 75% and 95% respectively 
at average cost per case completed identified with these respective time frames. 
The display will appear as the example for data display VI immediately following 
with the exception that there will be automatically, in this instance, a fourth 
category at the top of the chart representing the incomplete after 18 months. 
Data Display #VA - Rate of Problem Completions - Of Confirmed Unwells 

A similar procedure will be employed to determine rate of problem completions 



113 

^^ingle problem sheets as distinct from cases). 

Data Display #VB - Rate of Screen Completions - Of Shows at Screening 

This follows the procedure discussed above with the base being the number of 

children who showed for screening during the base six months and evaluating the 

screening completion rate for these children at the end of three and six months. 

Data Display #VC - Rate of Case Completions - Of Eligibles for Rescreening 
This follows the procedure discussed previously with the base being the 

number of children designated (eligible) for rescreening during the base six 

months. 

Data Display #VD through K - Rate of Case Completions - Of Confirmed Unwells: 
Condition - Vision Problems (Problem 16 from Screening Sheet, Chapter IX ) 

This follows the procedure discussed previously with the base being the 

number of problem sheets with the confirmed condition of vision problem being 

jj^identified during the six months prior to the day ending the report period and 

the number of these that were resolved at the end of six months and sample groups 

of 50 with the condition for the 7-12 and 13-18 month group respectively, at 

the respective average cost of case completion. 

Other displays relating to the specific problems stipulated on the model 

display following will be included and in each case the 7-12 and 13-18 month 

rates will be predicated upon sample groups of 50 in each time phase for each 

condition. 



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115 



Data Display VI - Project Impact - General Status of Child Health 

This is an outcome measurement of the impact of the EPSDT program on the 
overall health of the children in the program and relates specifically to changes 
in the healthiness rating of children over time. The healthiness rating, its 
purpose, and guidelines for utilization are discussed in Annex A, Chapter VII, 
and Chapter IX-B. 

If EPSDT is an effective program, the healthiness of children should im- 
prove over time. The purpose of this display is to reflect the actual changes. 

The format of the display is similar to those preceding, with a base point on 
the left (phase I) and reference points each quarter (or semi-annually) for the 
duration of the project. The nine healthiness ratings are consolidated into 
three groups of (1) ratings 7-9; (2) ratings 4 - 6; (3) ratings 0-3. 

Each quarter the number of healthiness ratings (new screens and rescreens) 
assigned will be totaled and grouped as indicated above. The percentage of 
these falling into each grouping will be plotted on the chart in a cumulative 
distribution of 100%. Over time this will reflect three horizontal areas 
fluctuating by differing percentages of distribution between the groups. As 
rescreens become more significant in the number of assigned ratings, the 
unhealthy category should decline and the healthier categories expand. 

If, for example, 600 healthiness ratings (new screens and rescreens) were 
assigned during the quarter and 100 fell into the category 1 - 3 (17%), 300 
into the category 4-6 (50%), and 200 into the category 7-9 (33%), the 
cumulative percentage distribution of the three categories over a 100% scale on 
the vertical axis would be as indicated on the following chart. A hypothetical 
projection over time is added for an example of a "probable" distribution. 




r 



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distribution) 



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(cumulati 



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118 



Data Display VII - Project Impact - Immunization Status 

This is an output measurement of the impact of the EPSDT program on the 
immunization status of children. It relates specifically to the changes in 
immunization currency over time. The immunization schedule and definition 
of currency is contained in Annex B, Chapter VII and Immunization Annex 
(Chapter IX-B). 

If EPSDT is an effective program the percent of children converted to a 
current status of immunizations within three to six months following screening 
or rescreening should progressively increase over time (an assumed preventive 
health cumulative spin-off). 

The rate or percent of immunizations current in any quarter will be based 
upon the cases screened or rescreened in the previous quarter and the number of 
these cases needing immunizations brought to a status of "current" ( "compl ete 
for age") during that and the current quarter. 

If, for example, 1000 children were screened/rescreened in the previous 
quarter and 900 of these children were determined to be in need of immunizations 
(non-current or incomplete for age) and as of the close out date of the current 
report period 500 of these children were now categorized as current the percent 
of immunizations converted to current in the quarter would be 56%. This point 
would be plotted on the chart and a line would be plotted to connect quarterly 
points to indicate the trend over time. 

This display may be predicated upon a sample study of 150 names of children 
screened in the previous quarter. 



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120 



Data Display VIII - Project Impact - Severity of Conditions Found 

This is an outcome measurement of the impact of the EPSDT program on the 
severity of conditions found in children. It relates specifically to the changes 
in conditions categorized by the practitioner as severe over time. 

If EPSDT is an effective program the percent of severe conditions found, 
particularly in rescreens, should decline over time. This assumes that the program 
has been successful through treatment in either eliminating the problem or 
modifying it to a moderate or mild category. 

The rate or percent of severe conditions found in any quarter (or semi- 
annually) will be based upon the number of problem sheets returned in that quarter 
(or six month period), both on new screens and rescreens separately, that are 
categorized as severe (rating of 4 or 5 on the severity scale of 1 - 5). 

If, for example, 400 problem referral sheets on new screens were returned 
from practitioners during the quarter and 100 were categorized as severe (4 or 5) 
the rate for severe conditions would be 25%. 

If, in the same period, 250 problem referral sheets on rescreens were returned 
from practitioners during the quarter and 50 were categorized as severe (4 or 5) the 
rate would be 20%. 

Both points would be plotted on the chart and two varying lines would 
connect the respective quarter points to indicate the trend in both factors 
independently and in relationship to each other. 

In addition to this evaluation of severity in relationship to problems in 
the overall^ additional displays will relate to severity by certain conditions 
in order to determine the status of severity in these conditions on a comparative 
basis and the response of these respective conditions to treatment programs to 
reflect reduced severity. 



{ 



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Data Displays #VIIIA through J - Severity of Conditions Focused - By Specific 
Condition 

The conditions to be reported are those designated on the model display 
following. 



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123 



Data Display IX - Project Impact - Health Problems Identified as Related to 
Previous Preventive and Acute Encounters in the 12 Months Prior to Screening 

This table depicts the impact of the numbers of preventive and acute health 
system encounters in the 12 months prior to the screen on the frequency of problems 
identified in the screening process. 

It is postulated that previous encounters that reflect preventive orientation 
will have a greater impact on reduction of problems encountered in the screening 
process than those previous encounters that were acute episodic in orientation. 

These data are intended to test this hypothesis. 

The factors employed in this display are the total number of children screened 
in the quarter (or other determined period) categorized into seven subgroups: (1) 

one previous preventive health encounter, (2) two previous preventive health encounters, 
(3) three or more previous preventive health encounters, (4) one previous 
acute episodic encounter, (5) two previous acute episodic encounters, (6) three 
or more previous acute episodic encounters and (7) no previous acute or preventive 
encounter. After the number screened have been categorized into these seven 
subgroups each subgroup will be further categorized into five subgroups; (1) no 
problems found, (2) one problem found, (3) two problems found, (4) three 
problems found and (5) four or more problems found. These data will be dis- 
played as indicated on the following model. 

Preventive health exposures and their numbers will relate specifically 
to the following entries in the box or sections of the screening sheet or 
child history titled, "Child's Medical Care During Past 12 Months". 



r 



(I 



124 



Checkups 

Well Child Coverage 
Private Physician 
Outpatient Clinic 
Hospital Emergency Room 
Screening Program 

Other (Specify *) 

*If specified as a preventive encounter 
Acute episodic encounters and their numbers will relate specifically to the 
following entries in same box or sections as for the preventive encounters, i.e.. 

Sick Visits 

Private Physician 
Outpatient Clinic 
Hospital Emergency Room 
Hospital Inpatient Admission 
Dentist 

Optometrist/Ophthalmologist 

Other (Specify *) 

*If specified as an acute encounter 
The following display includes as an example data based upon 1415 screens 
in a quarter with a hypothetical idealized distribution. 



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126 



Data Display #X - Project Impact - Medicaid Expenditures Before and After 
Screening (12 Months Before and 0-12 and 13-24 Months After) Based on Sample 
Data 

This is an outcome measurement of the impact of the EPSDT program on 
Medicaid expenditures for health services one year and two years subsequent to 
the screening. 

If EPSDT is an effective program. Medicaid expenditures for health services 
for children in the second year following screening should be less than that 
expended in the year prior to screening. 

The status of expenditures in the first year following screening may be 
higher than in the year prior to screening because of treatment costs for 
correction of problems found on screening. 

Both of these impact possibilities need determination, which is the purpose 

of these data and this analysis. 

Data from State Medicaid tapes (files) will be necessary to complete this dis- 
play. A sample should consist of a number equivalent to 15% of the total screens 
completed in the previous quarter (or other determined period). Of 500 completed 
screens in the previous quarter, 75 names (500x15%) of children who were screened 
in that quarter two years previously and are still active or eligible will be surveyed 
through the State Medicaid files to ascertain total health expenditures one year 
prior to screening and one and two years subsequent to screening, respectively. 
The total costs for each category will be averaged per child and the averages re- 
flected as indicated on the following sample display. This display will be based 
on total dollars for these children for all conditions. 

On a semi-annual basis, the December 31 and June 30 reports, the costs contained 
in the two inclusive quarterly reports will be evaluated and reported by disease 
condition to determine expenditure trend over time by condition. Fifty (50) cases 
per condition will be the minimum sample appropriate to this analysis. 



127 



Data Displays #X A through J - Semi -Annually as of December 31 and June 30 - 
Project Impact - Medicaid Expenditures by Condition Before and After Screening 
(12 Months Before and 0-12 and 13-24 Months After) . 

The conditions to be reported are those designated on the model display 

f ol 1 owi ng . 



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129 



Data Display #XI - Project Impact - Child Health Services Utilization by Type 
12 Months Before and 0-12 and 13-24 Months After Screening Based on Sample Data 

This display depicts the utilization of health services by type 12 months 
before and 0-12 and 13-24 months after screening. Its purpose is to determine 
and reflect increased or decreased utilization by type. 

The source of data will be from the same sample utilized to construct 
display X . 



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131 



MODEL FORMS AND ENTRY EXPLANATIONS 

As previously indicated in Section III (Common Data Base), data elements 
relating to family and child health and welfare are collected (inputted) 
through the means of three principle forms, i.e.. 

Registration Sheet 

Screening Sheet (and Immunization Annex) 
Problem Referral and Case-Monitorina Sheet 

The number of copies, style' of forms , distrubution of copies in time, 
etc. are specified in Section X (Data Processing Instruction). 

The Registration Sheet contains information pertaining to identifica- 
tion of the child, its siblings, parents and head of household status. 
Medicaid eligibility, welfare eligibility and status as well as sources 
of income and occupations. 

The Screening Sheet contains information pertaining to the identifica- 
tion and screening status of the child, certain previous health experiences, 
basic measurements and vital signs, health problem ICDA categories and 
38 disease/injury problem conditions, information on the family and child 
health history, specific diagnostic tests and measurements, physical 
examination and observation indicators, problem sheet origination indicators; 
healthiness rating and indication of screener's identification. An 
Immunization Annex is provided to be utilized as a separate sheet or as 
a reverse side to the screening sheet. This annex contains general 
information on immunization requirements, schedules and intervals by age, 
as well as being designed to reflect the current status and immediate 
(4 month projection) future requirements for a specific child. 



132 



The Problem Referral and Case-Monitoring Sheet contains information 
pertaining to the child's identification, provider referral, problem for 
which referred, provider's diagnosis and resolution through treatment 
or referral and requirement for follow-up as well as information maintained 
by the case monitor on the status of the case through the EPSDT system. 

A supplemental form, the EPSDT-Family Contact and Screening Appoint- 
ment Card , although not a component of input to the common data base, is 
a means to measure, (1) the number of family contacts per case-finding 
aide per designated hours of work (establishment of a work measurement 
guide), and (2) rates of "shows for screen" per contact per case-finding 
aide of various qualifications in the case finding subsystem. The form 
can also serve as a contact index as related to eligibles (a work sheet) 
for case-finding aides. An example of the form is as follows. 



(See following page) 




f 



133 



EPSDT'-FAMILY CONTACT AND SCREENING APPOINTMENT CARD 


Father's Name: 


SSN: Medicaid No. 


Last 


First 


Mother's Name: 


SSN: Medicaid No. 


Home Address 


Street 


Apt. Zip Code Telephone No. 

(For contact) 


Willing to Participate | | 


Consent to Screening | | Date of Contact 


in EPSDT Yes 


Appointment Yes 



Children Eligible in Household 



Name 

Last First Age Sex Uate for Screen Where Trans. Needed 

1. 

2. 

3. 

4. 

5. 

6. 



Name of Case Aide 



Comment : 



A family contact form will be initiated by the case-finding aides for 
each personal visit contact (a face to face meeting with a program eligible 
head of household is a contact). 

The entries to this form are generally self explanatory. Space is 
provided for both the mother's and father's name . The primary interest 
is in identifying the head of the household, be it the father or the mother. 
If it is neither enter the name (print) of the head of the family (household), 
line out (mother or father) and insert the appropriate designation -- 
stepmother, grandmother, aunt. It is imperative that names be spelled 




133a 



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134 

correctly, and Social Security numbers and Medicaid numbers be entered 
correctly. 

The home address , apartment number , Zip Code and telephone number 
(one that the mother has or generally receives calls on) are important 
to the case-finding aide as well as to the data system for identification. 

If the mother (head of household) is willing to participate in the 
EPSDT program by consenting to the children in the household being screened, 
check the box [ | YES. It is assumed that if not checked YES the 
"head of household" has refused to participate in the program. 

If the head of household has indicated willingness to participate 
in the program efforts should be made at that point to make a specific 
appointment for screening for one, several, or all of the children. If 
the head of household consents to a screening appointment check the 
box I I YES and enter the location and time for the appointment opposite 
each child's name in the lower section headed, " Children Eligible in 
Household . " 

If a check "Yes" has been made indicating a willingness to participate 
in the EPSDT program and no check "Yes" is entered consenting to the 
appointment at the time of the initial contact it is assumed that the head 
of household did not feel free to commit to an appointment at that time. 

The system provides* that at least two additional efforts should be 

subsequently made by telephone, personal contact, etc., to schedule the 

children for a screening appointment. If success in appointing is not 

achieved by the third contact the case-finding aide may assume that 

"the family declines further participation" and make such an entry in 

the "Comment" space at the bottom of the form. The family (children) 
*Refer to EPSDT Demonstration Model Flow Chart, Page 52 



t 



135 



will then not again be contacted (if they remain program eligible) until 
the next normal periodic rescreen sequence for their ages by case- 
monitoring personnel . 

In the section "Children Eligible in Household" enter the names, 
ages and sex for all program eligible children in the household. 
CORRECT SPELLING OF NAMES AND AGE (in years and months at time of date 
of contact, e.g. 1 yr 6 mo.; 9 mo.; 7 yrs 3 mo.) IS VERY IMPORTANT -- 
PLEASE PRINT . 

As previously indicated, if the head of household consents to 
appointment at the time of initial interview (contact) enter the date 
and location and an indication of whether transportation is needed 
and can be provided . 

If the head of household did not agree to appointing at the initial 
interview, but does at one of the next two contacts , check the box | [ 
YES adjacent to "Consent to Screening Appointment" and enter the date and 
location for the screening. 

EXPERIENCE IN OTHER EPSDT DEMONSTRATIONS AND ON-GOING PROGRAMS 
INDICATES THAT SUCCESS IN HAVING EPSDT SCREENING APPOINTMENTS KEPT 
DEPENDS SIGNIFICANTLY ON A MINIMAL LAPSE OF TIME BETWEEN THE DATE OF 
CONTACT AND THE SCREENING APPOINTMENT . THE HIGHEST RATES OF SUCCESS 
IN SCREENING APPOINTMENTS KEPT WERE WHERE THIS PERIOD WAS LESS THAN 
FIVE DAYS . 

The date of contact to be entered is the date of first "eye to 
eye" contact with the head of household for the purpose of "selling" 
the EPSDT program and appointing the children for screening. 



r 



1 



( 



136 



Name of Case Aide . The case-finding aide should print her name in 
this space at the same time she enters any other information on the form. 

A comment space is provided for the case aide to make any explanation, 
particularly in those circumstances where the head of household indicated 
a willingness to participate in the program but the aide was unable to 
obtain agreement for a screening appointment in the initial or two sub- 
sequent contacts. 



{ 



Child'i Name I 



I I I I I I I I 



EPSOT - REGISTRATION SHEET 

rn 



Date 



Fint 



Man 



TTTT 



Day Yt 

Sex 



Child's Project No. 
Child'* Address _ 



Child's Birthdate 



Child's Medicaid 
or O.P.W. Number 



Uon 



Numbtt 



Strmt 



Day 

iApV No. If Appropriaul 



Yr 



n 



Referred by: (check appropriate box) 



Oty or Town 



Zip Coih 



Telephone No. for Contact 



Cenius Tract 



Lut 5 Digitt 



Newspaper Ad 
Radio Notice 
T.V. Notice 
Mailed Flyer 
Letter Notice 
Wallcin 



□ 
□ 
□ 
□ 
□ 
□ 



Welfare Worker 
Other Agency 
Specify 



O 
O 



Transportation (check appropriate means) 

To Clinic: Own Car □ Friend/Rela. □ 
Walk □ Clinic Car/Bus □ 

Bus/Subway □ Other (Gov't □ 
(Public Trans.) Sponsored) _ 



Length of time on 

Medicaid: 



Neighbor 
Other 
Specify. 



P 

O 



(Current Eligibility) (Monthtl 



(Sptclfyl 



Mottwr's Name 



Lmt 



Fint 



U.I. 



Address. 



(It different from child'tl 



Number 



Street 



S.S.N. 



'Birthdate 



City or Town 



Zip Code 



Medicaid No. 



Man 



Dey 



Yr 



Telephone No. for Contact: Work 

Home 



1 I Currently □ Yes -* Full time? O 
Employed: □ No Part time? □ 



Occupation: 



How long on 
Present Job 



Work Address:. 



Name of Company or Perton 



Number 



City or Town 



Street 

Zip Code 



Monthi 

Do you have someone you call 
upon for help in case of family 
protdems, accidents or illness? 
Yes □ No □ 



Salary 
Per Week 
(Dollant 



Education: 

tNo. Yn. 
Completed) 



m 



Father's Name 



Laa 



Address. 



(If different from ehild'tl 



Number 

City or Town 



Street 



Birthdate 



Mon 



nn 



Day 



Yr 



Telephone No. for Contact: Work 

HomefT I l-l I I T1 




Currently □ Yes Full time? O 
Employed: □ No Part time? □ 



Occupation: . 



How long on 
Present Job 



Months 



Salary 
Per Week 
IDollant 



Work Address: 



Name of Company or Perton 



Number 



Street 



Education: 

(No. Yn. 
Completed) 



City or Town 



Zip Code 



Sources of Household Income: 



Salary per week 
ADFC per week 
Public Asst. per week 
Social Security per week 
Retirement per week 
Other (specify) 



Total Per Week 



Who is Child's Head of 
Household? (Check one) 
Mother □ 
Father D 
Grandparent □ 
Other relative □ 
Other (specify) □ 



Who is Child's Health Decision 
Makei? (Check one) 
Mother □ 
Father □ 
Grandparent □ 
Other relative □ 
Other (specify) □ 



What is Source of Medical 
Payments? (Check box or boxet) 



Medicaid 
Private Insurance 
Group Insurance 
Cash 

Hospital District 
Federal Project 
Other 



□ 
□ 
□ 
D 

□ 
□ 
□ 



Other Children in Household 



Name 



Brother Sister Other 
, (Check one) 

1 □ a □ 

2 □ □ □ 

3 □ □ D 

4 a □ Q 
6 □ □ □ 



Age 



First 



-8 
9 
10 



Brother Sister 
(Check one) 

□ □ 
D □ 

□ □ 

□ □ 

□ □ 



Other Age 

D 

□ 

□ 

□ 

□ 



Name 
Last 



First 





( 



138 



Entry Instructions - Registration Sheet 
1. Date: Enter numerically, e.g., 



4. 
5. 



7. 



Date 






9 





CO 


7 


4 



Mon Day Year 

Child's Name : Print in the boxes provided, starting from the left. If 
the name should contain more letters than boxes on the form, print the 
remainder out to the side, e.g.. 



Child's Name 



w 


i 


1 


1 


i 


a 


m 


s 





n 




















Last 








F 


r 


e 






r 


i 


c 


k 





Initial 



First 

Sex: Check the appropriate box, e.g.. 

Sex I j or 

M F 

Child's Number : Local project number for child, if used. 
Child's Birthdate: Enter numerically, e.g.. 



Child's 
Birthdate 






5 


3 


1 


7 






Mon 



Day Year 

6. Child's Medicaid or Department of Public Welfare Number : En%er in the 
spaces provided, starting from the left, e.g.. 



Child's Medicaid No. 



4 


9 


7 


2 





3 


9 


6 


5 





3 



Child's Address : En^er the address of the child's home, e.g., 
Child's Address 10256 Porter Street 3F 



Number Street 
Houston 



Apt. No. (if appropriate) 
77643 



City or Town 



Zip 



( ^ 



139 



8. 



Telephone Number for Contact ; Enter the telephone number through which 
information about the child may be obtained or relayed, e.g.. 



Telephone No. 


6 


7 


9 




4 


1 


8 


4 


for contact 











9. Census Tract : In some demonstrations, census tract is the locational 

frame of reference for measuring "penetration". Enter the last five 
digits of the census tract of the child's home, if known, e.g., if the 
census tract designation was 6540099, the entry would appear as 



Census 













Tract 


4 





9 


9 



10. Transportation to Clinic : Information is desired to ascertain the value of 
government sponsored transportation in impacting upon the utilization of 
EPSDT. Such government sponsored transportation might be 
"Clinic car or bus" | / j or 

"Other (Govt. Sponsored) I ./ I Caseworker's car" or 



□ 



11 



"Other (Govt. Sponsored) I ^ I Taxi (fare provided)" 

I I (specify) 

Length of Time on Medicaid ; Because of the frequent change of status of 

families eligible for Medicaid, it is desired to ascertain the average 

length of time children are currently eligible prior to action being 

taken to have them screened. Enter numerically the number of months, e.g. 

Length of time on Medicaid 21 

(Current Eligibility) Months 

12. Referred by: The means by which mothers of eligible children learn of EPSDT 

and act to have their children screened is of significant importance in 



f 



140 



evaluating the functioning of the case finding subsystem. The primary 
factor being identified here is what or which was the one main precipi- 
tating factor leading the mother to bring the child for screening. 

13. Mother's Name ; Enter the name of the child's mother or, in the absence of 

the mother, the person functioning as the "mother" in the home in which 
the child lives, such as stepmother, guardian, aunt, grandmother, etc. 
The primary consideration in the absence of the child's mother is 
which female in the household could claim the child as a basis for 
welfare assistance. 

14. Address ; Enter the address only if it differs from the child's as recorded 

in item 7. 

15. Social Security Number ; This constitutes an additional check on identifi- 

cation. The entry is obvious. 

16. Medicaid No. ; This constitutes a check on EPSDT eligibility and serves 

as an identifier of source of medical payment. The entry is obvious. 

17. B irthdate ; This serves as an additional check on identification and 

provides a basis for relating the age of the mother to response sensi- 
tivity to EPSDT, e.g., do the younger mothers have a greater sense of 
appreciation of preventive health? The numerical entry is styled the 
same as for the child (item 5). 

18. Telephone Number for Contact ; This information assures location of the 

mother at work or home to transmit or obtain information concerning 
the child. This information relates to a telephone through which the 
mother may be reached, such as a neighbor or hall phone, it is not 
limited to a family or household phone, which the family may not have. 
The numerical entry is styled the same as for the child's (item 8). 



141 



19. 



20. 



21 



22, 



23. 



24. 



Currently Employed : This entry provides information on the employment 
status of the mother and whether she works full time (40 hours per 
week or more) or part time. The entry style is obvious. 

Occupation : This entry identifies the occupation of the mother, whether 
or not currently employed. Enter the occupation in the following manner: 
"Occupation: Beautician or Cook or Sales Clerk, etc. " 

Work Address: If currently employed, enter the address of the work site. 



e.g 



• » 



"Work Address 



Royal Crown Cafeteria 



Name of Company or Person 



113 



Number 
Houston 



Broadway 



Street 



73234 



City or Town Zip Code 

How Long on Present Job : This entry gives some indication of work and 
income continuity. If the length of time exceeds 99 months (the maxi- 
mum entry), report 99, e.g., 

II 

" (six months) or 



"How long on 
Present Job 







(10 years) 



Salary per Week : This entry provides information on earned income per week, 
whether part time or full time. If salary is by the month, divide by 4 
to report the weekly salary. Report gross salary (before authorized 
deductions) in full dollars, e.g.. 



"Salary Per Week 
(Dollars) 











(60 dollars per week) 
(240 dollars per month) 



Emergency Assistance - (Psychic Reinforcement) : This entry provides infor- 
mation on the psychic reinforcement available to the mother in time of 



I 



{ 



142 



emergency. The American Academy of Pediatrics has suggested that a 
negative response to this question, indicating a sense of isolation, is 
especially relevant in identifying the mother who needs special support 
if her child is to be protected from neglect or other forms of problem 
creating child-parent relationships. A negative answer to this question 
should be used as a notice to the screening personnel (completing the 
screening sheet) to be particularly observant of the child for 
symptoms of abuse or neglect. 
25. Education : This entry provides information on the years of education 

completed by the mother and will be used to seek correlations between 
income, occupation, and utilization of EPSDT. Report the entry as 
follows: 
"Education 

(No. of years completed) 



" (Attended 11 years but left school 
at the end of the 10th grade) 

Entries 26 - 37 pertaining to the father are explained in relationship to items 

13 - 25 pertaining to the mother except as indicated below: 

26. Father's Name ; Enter the name of the child's father or "stepfather" 

living in the home recorded for the child (item 7) or male functioning 
as the male head of household in which the child lives (item 7), such as 
an "Uncle" or "Grandfather". 

27. Address: Enter the address only if it differs from that of the mother as 

as recorded in item 14. 

28. Social Security Number 

29. Medicaid Number 



" (Completed grade school - 8 years) 







( 



J 



U3 



30. Birthdate 

31 . Telephone Number; for Contact 

32. Currently Employed 

33. Occupation 

34. Work Address 

35. How Long on Present Job 

36. Salary per Week 

37. Education 

38. Sources of Household Income : This item reports all sources of income to 

the household through all means by week. Income to the household is 
that income to all persons living on a full time basis in the household 
such ascmother, father, grandparents » etc. The Information relates to 
gross income in round dollars. The entry style is evident. 

39. Who is Child's Head of Household? : This item identifies the person in the 

household who is the "head" of the household, such as the decision 
maker, main source of income, etc. The entry style is evident. (See 
No. 40, below.) 

40. Who is the Child's Health Decision Maker? : This item identifies the indi- 

vidual who may be contacted regarding health decisions concerning the 
child. Check the appropriate box, e.g.. 

Who is Child's Who is Child's 

Head of Household? Health Decision Maker? 
(Check one) (Check one) 

Mother 
Father 
Grandparent 
Other Relative 
Other (Specify) 




i 



144 



41. What is the Source of Medical Payments? : This item identifies the possible 

sources of payment for screening and, if appropriate, diagnosis and 
treatment of any health problems identified. All the sources should be 
identified.. Check appropriate box or boxes. The entry style is evident. 

42. Other Children in Household : This item identifies those other children in 

the household who are potentially eligible for the EPSDT program. 
Possibilities for listing 10 other children are provided. Check the 
box indicating the relationship of the other children in the household 
to the child currently being registered, and enter the age, and last 
and first name. 



( 



1 1* 



145 



EPSOT SCREENING SHEET 



Date 



rr 



Child's Name 



;hild s Birthdate 



Sex 



IPntuI 



Child's Medicaid No. 
or D.P.W. No. 



Ethnicity: 



White (Anglo) CJ 
Black □ 



Caretaker's Name (Parent/Guardian) 

(It d'Ifervnt from chtld'sl 



Last Only 



Screening 
Sequence: 



Original EPSDT 
Periodic Rescreen 



□ 

D 



Visit No. 
Visit No. 



n Day Yr 

□ orD 
M F 

American Indian 
MexicanAmer. 

12 3 4 

12 3 4 



Child's Project 
1.0. No. 



I I Puerto Rican I i 
D All others I I 

Screening no* complete? 

Yes I J 



Child's Medical Care During Past 12 Months 
Number of 
Checkups Sick Visits 

Well Child Coverage 
Private Physician 
Outpatient Clinic 
Hosp. Emergency Room 
Hosp. (Inpatient) Adm. 
Dentist 

Optometrist/Ophthal. 
Screening Program 

Other (Spec.) 

// none, leave blank, if unknown, enter 99 




Child's Previous Health Experience 

Any time previously 

Sickle Cell Screen U 

Within past 12 months only 

Physical Exam n 

Hearing Test □ 

Vision Test □ 

Lead Screen □ 

Urine Analysis □ 

Blood Analysis n 

Dental O 

School Physical lor other) □ 

Specify 



Vital Signs and Measurements 

Height: (inches) 

Weight Ib/oz. 

Head Circum: (inches)... 

Temperature Oral . ° 



Rectal 



Pulse. 



. Respirations . 



Blood Pressure (Sys)_ 



. (Oias). 



Staff Codes 



Nurse (Grad. M D. 5 

or 3vr dipl.) 1 D.D.S. 6 

LVN 2 P.A 7 

Nursiny aido 3 Other 8 
Volunteer 4 



S<aff codes o1 
persons complettng 
each ol lest two 
coturrms below. 



Print last name - person completing last Iright) colunrtn) 

and Child's Healthiness Rating ICurrcml 
(Circle most appropriate rating) 

Unwell 1 Well 

123456789 



PROBLEM CATEGORY 



SOURCES OF PROBLEM DETERMINATION 



01 



02 



03 



i5r 



05 



06 



07 



08 



09 



12 



13 
14 



15 
16 



17 



18 



19 



21 



22 



23 



24 



25_ 
"26 



IT 



28 



29 



30 



31 



32 



33 



34 



1 



37 



38 



Disease/ Injury Designation 



ICDA 
Range 



Medical Histories 



Family 



Child 



Do any members of the family 
or child have a history of 
1/ if yes) 



Tests & Measurements 



Problem Sheer 
Originated? 



Infective Diseases and Parasites 



000-136 



Pinworms 



TB 



Bacterial infections (scarlet fever/meningitus) 



All others in category (inci: lice, diarrhea, poxes, VD) 



Nutritional Deficiencies, Endocrine & Metabolic Dis. 



Diabetes 



Nutritional deficiencies (avitaminosis/obesitv) 



Other endocrine & metabolic dis. (hyperthyroidism, etc.) 



Blood Diseases (and blood forming organs) 



Anemias (iron and other deficiencies) 



Sickle cell trait or anemia 



Other blood diseases (inc purpura, etc.) 



Mental Disorders 



Behavioral/emotional 



Learning disability 



Mental retardation 



Speech disorders 



Nervous System and Sense Organs 



Convulsive disorders 



Vision problems refractive (sight loss) 



Eye problems - diseases (strabismus, etc.) 



Hearing problems (hearing toss) 



Ear problems ■ diseases (otitis media, etc.) 



Other diseases in category (epilepsy, sclerosis, etc.) 



Circulatory System (Heart, arteries, lymphatics, etc.) 



All conditions (incl. murmur, infarction, etc.) 



Respiratory System (nose, throat, lungs, etc.) 



Acute respiratory infections (colds, flu, pneumonia, etc.) 



Chronic respiratory infection (frequent recurrences of) 



Asthma 



Hay fever and other allergies 
Other diseases in category (pleurisy, etc.) 



Dit/estive System (iimi/th. stoiiiach, intestines, etc.) 



Dental caries 



Other dental and oral problems 



Hernias 



Other diseases in category (colitis, peritonitis, etc.) 



Genito-Urinary System (kidneys, bladder, genitals) 



All conditions (kidney, bladder, genitals, etc.) 



Skin 



All conditions (incl impetigo, boils, eczema) 



Musculoskeletal (bones, )oints, connective tissue) 



All conditions (incl. skeletal deformities, arthritis, etc.) 



Birth Deducts 



All conditions (incl: cleft palate & lip, club foot, etc.) 



Birth Prnhlciiis (perinatal) 



All Lonrlitions (incl: abnormal labor and difficult birth) 



Accidents. Poisoniny and Violence 



Lead [X)isoniny 



Other conditions in category (incl fractures & other injury) 



All Other Cnnditioiis ( 140 239, 630-678, 780 796) 



All others (incl neoplasms, abortion, symptoms (enuresis) ) 




Immunization Annex - Reverse Side or Accompanying Sheet — 



4 





146 



Entry Instructions— Screening Sheet 

1. Date Refer same item - Registration Sheet 

2. Child's Name 

3. Sex 

4. Child's Project I.D. No. 

5. Child's Birthdate 

6. Child's Medicaid or DPW No. 

7. Ethnicity: This item indicates the ethnic origins of the child. The informa 

tion is utilized to order or not order certain tests, i.e., sickle cell 
for black children and to establish whether certain illness conditions 
are more prevalent in one group than another. Most people of North 
American and European ethnicity are generally categorized as Anglo, 
e.g., German, French, Italian, Irish, Polish, Canadian, Russian, etc. 
Those of the Far East, of Japanese, Chinese, Korean ethnicity will be 
categorized as "all other", as well as those from South and Latin 
American countries except Mexico. The ethnicity categories indicated 
represent those minority classifications who are in the greatest 
need of improved healths care. Check the appropriate box. 

8. Caretaker's Name : This item assists in the identification of the child and 

family. Enter the child's caretaker's last name, if it differs 
from the child's last name. This should be the mother, or if no 
mother is in the house, the person functioning as the mother in the 
household. If no one functions as the mother, then the father's 
last name, or the person functioning as the father should be entered. 
9. Screening Sequence : The child will be eligible for an original EPSDT 
screening and then, in accordance with the state or demonstration 



4 



147 



plan, be eligible for periodic rescreens. This entry will indicate 
whether this screening sequence is the initial screen or a rescreen. 
Check the appropriate box. 

Some screening completions require more than one visit. It is 
considered necessary to ascertain the impact of multi-visits on 
screening and case completions. In this instance, circle the number 
that the current visit constitutes in the ongoing screening sequence. 
In the initial visit the screener would have indicated "(l}". On 
a subsequent second visit, using the same screening sheet, the entry 
would appear as "(j) (z) 3 4 and if, for some unusual reason^ a 
new screening sheet was initiated for this second visits the entry 
would appear as " 1 (z) 3 4 ". 

Screening Now Complete? : It is important to identify the completion of the 
screening sequence. The screening is complete when the family and child 
medical history data has been entered in the appropriate columns, 
when the physical examination and the results of all required 
tests have been returned, when the child's healthiness rating 
has been entered and when the staff code for the persons completing 
the two right columns and the last name of the person completing the 
extreme right column has been entered. Check "Yes" when complete. 

Child^s Medical Care During Past 12 Months ; This item identifies the place 
or type of medical care that the child may have had during the 
previous 12 months for an acute illness (sick visits) or as a pre- 
ventive health measure (check-up). It is an indicator of the child's 



148 



general health and the preventive health orientation of the parents. 
Enter the appropriate numerical data, e.g.. 
Child's Medical Care During Past 12 Months 

Number of: 



Check-ups Sick Visits 



Well Child Conference 
Private Physician 
Outpatient Clinic 
Hospital Emergency Room 
Hospital (Inpatient) Admissions 
Dentist 

Optometr i st/Ophthalmol ogi st 

Screening Program 

Other (Specify) 



9 9 






1 







1 




1 































The blanks above indicate no visits or check-ups. The numbers 
(except 99) indicate the number of visits or check-ups in the appropriate 
category in the previous 12 months. The 99 entry indicates some visits 
but the exact number is unknown. 
Child's Previous Health Experience Information : This item identifies var- 
ious health tests and physical examinations that may have been performed 
for the child in the previous 12 months and for the sickle cell screen 
at any time in the past. The purpose of the question is to avoid, if 
possible, duplicating the test(s), their inconvenience to the child and 
parents, and their costs, rf the results can be obtained for use as part of 



149 



the EPSDT screening. Check appropriate box or boxes. The entry style 
is evident. 

12. Vital Signs and Measurements 

Height ; Enter height in inches; e.g., 34 1/2 
Weight : Enter weight in pounds; e.g., 63 1/4 

Head Circumference ; Enter head circumference in centimeters ; ^ 

Temperature ; Generally children under three years of age will have 

their temperature taken rectal ly and those over three years, orally. 

Enter the appropriate temperature, e.g., 

"Temperature; Oral 98.6° " 

or 

Rectal 

"Temperature: Oral _" 

Rectal 99.6° 
Pulse : Enter the pulse rate per minute, e.g., 72. 
Respirations : Enter the respirations per minute, e.g., 18. 
Blood Pressure : Enter the blood pressure as determined by sphygmomanometer, 
e.g., "Blood Pressure (Sys) 120 (Dias) 80 

13. Staff Codes ; A single person should be designated as the primary screener 

for each child. This primary screener will, as. a minimum, complete the 
review, and if appropriate, the entries in the last two columns. Other 
subordinate screening assistants may do and complete the entries for 
Medical Histories, and Tests and Measurements. Certain tests will be 
executed by contract laboratories and the results provided to the screen- 
ing activity. If the contract facility does not indicate a normal /abnormal 
finding, indication'ef such d^terminatibh^^hd<uld be accbrrtpTiVhed by the 
primary scfeenfer^and- appV^8^f^i&l|lfe l§ftft<t^Hes made ih-ttie c^ilumn^^l'ie^yeh'"^ 



4 



9 



150 



"Result" or "Retsst"k The 'prtmarypscreener .shoQtd"|!)rint his/her 
namd '^in--&h# "boxes tftd<icie^d*:and enter the G6de of^hls/her skH^^j- y 

category -1^ the 'dppr^pftate boxes provided. 
Child's Healthiness Rating : The healthiness rating is the screener's 
general overall impression of the child's current health in terms of 
a numerical rating on a scale of 1 to 9. The intent is to indicate 
the ability of the child to learn, perceive and play on the basis of 
medical or social factors. In arriving at a rating, use the following 
guidelines: 

a. Compare each child to the general population of children, not just 
those from the demonstration catchment area. 

b. Rate healthiness to reflect the total health picture, considering 
numerous problems found in a child as having the effect of lowering 
the rating you would give any one of those problems. 

c. Rate children having permanent, uncorrectable disabilities accord- 
ing to their general health level. Consider adjustment to the 
disability and degree of rehabilitation achieved as reflective of 
healthiness. 

d. Use the categories listed below, together with their definitions 
and clinical examples, only as guidelines in determtiiing whereoen 
the continuum of health 0-9) a child falls. 

Unhealthy (1,2): Has life threatening problem if remains untreated 

Cyanotic heart murmur 

Bacterial pneumonia 

Severe uncontrolled diabetes 

Severe failure to thrive (psychosocial origin) 



151 



Moderately Unhealthy (3,4): Limited in ability to learn, play or 
perceive until somewhat difficult correction is accomplished, e.g., 

Anemias below 28 HCT 

Severe visual or hearing loss 

Mental or motor development delays 

Malnutrition 

Severe obesity 

Moderately Healthy (5,6): Requires a slight change in life style or 
relatively simple medical control or correction, e.g.. 

Urinary tract infection 
Umbilical or inguinal hernia 
Ringworm with secondary infection 

I mpetigo 

Intestinal parasites 
Anemias, 28 - 33 HCT 
Asthma 

Tonsillar hypertrophy 
Mild hearing or visual loss 
URI with otitis media 

Healthy (7,8): Has no observable disease, or only that which is 
brief and self limiting {may include dental caries). 

Mild URI without otitis media 
Few dental caries 

Superior Health (9): No observable disease. Exhibits evidence of 
positive health habits. Is alert and has good muscle tone. 
The "picture of health". 

Circle the rating considered to be representative of the child's 
overall healthiness. It must be emphasized that the above ratings are in- 
tended to be indicators for evaluative purposes and are, by this nature, sub- 
jective. The purpose of collecting the data is to make comparisons over time 
as to the screening and treatment impact on children. On rescreens, for 
example, comparisons will be made individually and collectively on the 
changes that have occurred in the general healthiness. If the program is 
effective, a significant trend toward improved healthiness should be 
encountered on rescreens collectively over time. 



152 



15. Problem Category, Sources of Problem Determination : The purpose of this 

section is to assist the screener in arriving at a conclusion as to 
when a health problem is suspected and whether or not to initiate a 
problem sheet for a suspected problem. Literally all the indicators of 
a problem, if they exist, will appear in this section. 
Problem Category ; Thirty-eight problem categories are indicated. These 
38 are those most commonly found in children and, in the main, are those 
conditions that, if neglected in children, can develop into chronic 
incapacitating conditions in later life requiring expensive and prolonged 
care to rectify. This listing is based upon the experience of other 
child health screening programs, e.g.. Head Start, Health Start, Child 
and Youth, and on the recommendations of this Institute's y\dvisory 
Council. The 38 conditions are grouped under 15 major classifications 
of disease used internationally^ which are mainly in terms of bodily 
functional systems, e.g., nervous system, circulatory system, digestive 
system, respiratory system, etc. This use of the International Classi- 
fication of Diseases (ICDA's) facilitates the tracking of cases (problems 
through the diagnostic and treatment subsystems to case completion and 
permits reasonably accurate comparisons with disease findings of other 
child health studies. No entries are required under the major heading 
of "Problem Category" which includes "Problem No.", "Disease/ Injury 
Designation", and "ICDA Range". 

16. Sources of Problem Determination; This section, with three major categories 



Eighth Revision International Classification of Diseases adopted for use 
in the United States, US DHEW, PHS Publication #1693, USGPO, Washington, D.C., 
1969. 



153 



i.e., "Medical Histories", "Tests and Measurements", and "Physical 
Examination and Observation", provides a systematic approach to the 
listing of indicators that would lead to the determination as to 
whether a problem should be suspected in any of the 38 disease/ injury 
conditions. 

17. Medical History - Family: The unshaded boxes in this column allows the 

screener to question the child/parent regarding specific current or 
earlier family medical experience and indicate the condition history 
in those problem areas wherein it is considered potentially pertinent 
to the current or future health of the child. 

Indicate with a check (/) each instance wherein an affirmative 
reply is received regarding members of the family (defined as father, 
mother, brothers or sisters, grandmother, grandfather) irrespective of 
where they live. 

18. Medical History - Child : The unshaded boxes in this column allows the 

screener to question the child/parent regarding current or earlier 
medical experience and evaluate the condition history in those 
problem areas wherein it is considered potentially pertinent to the 
current or future health of the child. 

Indicate with a check (/) each instance in which an affirmative 
reply is received concerning the child. 

19. Tests and Measurements ; The various tests and measurements considered a 

basic component of screening are listed on the same line with the condi- 
tion (problem) they are usually employed to detect, e.g., the pinworm 
test for pinworms. 



4 



154 



Required? Under the "required" column, check (/) those required. First, 
refer to item 11 at the top of the screening sheet ("Child's Previous 
Health Experience") to ascertain if the child has received the respective 
test in the past 12 months. If this child has received the test 
ascertain from the mother or child where the test was given and make 
a determination as to whether the results can be readily obtained. If 
duplicate copies are not readily obtainable re-schedule the test by 
a check (/) under "required". 

The "sickle cell test" is normally only required for black 
children and generally only once. 

The "lead test" is normally only required in certain areas in 
which the housing was generally constructed prior to 1950 -- when high 
concentrations of lead were used as a dryer in house paints. 

In the instance of vision tests, indicate the type test normally 
provided at the respective screening site, e.g.. 

Required 

Snellen _____ 
Titmus 

Other (Spec. Autp- 

refractor) x 

In the instance of hearing tests, indicate the type test normally 

provided at the respective screening site, e.g.. 

Required 

Audiometer x 

Impedance Bridge 

Other (Spec: ) 



155 



Results : The American Academy of Pediatrics recommends that when the first 
result of certain tests is abnormal, the child should be retested . 
If this is the State/Community policy, an abnormal entry should not be 
made until it has been confirmed by retesting . 

Upon completing the test(s), check if the results were in the 
range of "normal or abnormal". It is imperative in this instance that 
a normal or abnormal indication ultimately be entered for each te<;t - 
marked as ^required". This is a computer check to assure that a test 
"required" is in fact given and a result received and recorded . The 
computer cannot indicate a screen completion unless this condition is 
met. 

See Annex A to this Section for Definition of Abnormal Results 

If abnormal on the first test (/) check the "Retest" column 
for that test/condition and make no entry in the "Result" column at 
this time.. Schedule the child for a retest of the abnormal finding. 
If the second test (retest) confirms the abnormal finding make an entry 
(/) under "abnormal" under the "Result" column and consider the test 
sequence completed. If the second test (retest) is normal make an 
entry (/) under "normal" under the "Result" column and consider the 
test sequence completed. 

If normal on the first test make an entry (/) under "normal" under 
the "Result" column and consider the test sequence completed. 

In certain instances, e.g.. Problem No. 22 - Acute Respiratory 
Infections - under "Tests & Measurements" is an indicator - "(Check TPR)" 
If any of these vital signs recorded in item 12 at the top of the 
Screening Sheet are outside the rarjge of normal as defined in Annex A, 
place a check under the "abnormal" column on the appropriate line. 



4 



f 



i 



156 



The same general instruction applies in the instance wherein the 
indicator "Check Blood Pressure^, "Check height & weight", "Check head 
circumference" is found. 

22. Physical Examination and Observation ; The unshaded boxes in this column 

directs the screener to look for certain primary physical" indicators 
of the presence of specific problems . 

Annex A lists certain gross indicators of a probable (possible) 
disease condition. If any of these are present in relationship to a 
specific problem place a check (/) indicating an abnormality suspected, 
e.g., 

Abn. Suspected 
Item 14 - Speech Disorders / 
(the child was observed to stutter - or could not verbalize certain 
sounds). 

23. Problem Sheet Originated : This section of the Screening Sheet represents 

the greatest application of judgment. It is the culmination of all 
other entries. The screener should examine each line of the sheet in 
problem number sequence from left to right. In any instance in which 
there is a check mark on that line (which is a potential problem indi- 
cator) a decision must be made as to whether the problem indicated is 
significant enough to justify origination of a problem sheet. In each 
case that the screener considers the indicator sufficiently significant, a 
check mark will be placed in the box | / | YES and a problem sheet 
originated. Each check in the right column requires the initiation of 
a problem sheet. In some instances there will be as many as two or 
three checks in the right column and in some instances four or more. 



4 



• 



t 



157 



(As a rule the experience of other child screening programs has been 
that roughly one-third of the children screened will have one or more 
medical problems requiring treatment and one-half will have dental 
problems requiring treatment). 

Quality control of screeners will be assessed by a professional 
review of the entries in the two right columns. The use of every check 
mark under the heading of "Sources of Problem Determination" as a 
basis to originate problem sheets will cause a number of falsely declared 
unwells (false positives) (which should be detected when the child is 
referred to a practitioner for diagnosis and treatment). This results 
in unnecessary practitioner visit costs. 

The opposite of the above situation is over caution in originating 
problem sheets where check mark indicators exist. This will cause a 
number of falsely declared wells (false negatives). Since the intent 
in the demonstration is to review (through the quality control process) 
only a small percentage of the "wells" it is obvious that an excessive 
number of real unwells will go untreated under these circumstances. 

In those instances in which a confirmed abnormal test result is 
recorded (a check in the "abnormal" column under the heading "results") 
the entry of a check mark in the right hand column on that line (problem 
sheet originated) is virtually automatic, e.g., an abnormal TB, sickle 
cell or hematocrit test result. 

Probably the most nebulous area in determining the sufficiency of 
an indicator is a check mark under family medical history. A general 
rule might well be that a check mark under family history in itself 



f\ 



158 



is not usually sufficient to generate a problem sheet but is a caution 
to the screeners to look closely for all other indicators concerning that 
condition. 

Equally nebulous, but of great national concern at the moment, 
is the problem of child abuse and neglect. Item 24 of the Registra- 
tion Sheet (Emergency Assistance - Psychic Reinforcement) is designed 
if a negative response is recorded for the question , to be an indicator 
of a potential child neglect situation. In the event of a negative 
response the screener should look closely for all other indicators of 
neglect, e.g., nutritional deficiencies (Problem no. 06), growth 
retardation (Problem no. 06), scars, bruises or other evidence of 
injury which are not explained (Problem no. 37). 



f 



IMP 



159 



IMMUNIZATION ANNEX - REQUIREMENTS, SCHEDULING and CONTROL 



Child's Name 



Child's Age 



Date 



□ 



Month Day ' Y«ar 



Child's Sex | | or | | Child's Project I. D. No. 



Years Month* 



Mai« F«niala 



IMMUNIZATIONS 



AGE AT SCREENING 



2-4 
Months 



4-6 
Months 



6-11 
Months 



12-17 
Months 



154-5 
Years 



6-13 
Years 



14-21 

Years 



CURRENT STATUS 



Routinely required 
for child this age? 



/II Required 



Has child had this 
immunization - in- 
cluding this visit? 



Enter 
Date Received 



Subsequent Immuniiiatloni 

current serlef (within 4 
months of this visit only) 



Date 
Required 



Date 

Received 



DTP 



#1 



TOPV #1 



DTP #2 



TOPV #2 



DTP #3 



TOPV #3 



MEASLES 



RUBELLA 



MUMPS 



DTP after age 18 months (#3 or 4) 



TOPV after age 18 months (#3 or 4) 



„_ after age 4 yrs. (#3,4 or 5) 
' (Td if given after age 6) 



TOPV after age 4 yrs. (#3,4 or 5) 



Td within last 10 yrs. 



KEY: 



DTP 



TOPV 



Td 



□ 



Diphtheria and tetanus toxoids 
combined with pertussis vaccine 

Trivalent oral polio 
vaccine 



Combined tetanus and diph- 
theria toxoid (Adult Type! 



DO AT THIS AGE 



DO AT THIS AGE IF NOT 
DONE AT PREVIOUSLY 
SCHEDULED AGE. 



'Enter "Date Required" only for immunisations to complete 
a current ongoing series such as DTP or TOPV. According to 
the schedules on this page no such date should be later than 
4 months of the current visit or an entry in the column "Has 
Child Had This Immunization?". Accordingly immunizations 
will be considered current only if there is an entry under 
"Enter Date Received" for each immunization (j) checked 
as required or there is an entry under "Data Received" 
matching any entry under "Date Required" under the 
overall heading "Subsequent Immunizations — Current 
Series Only." 



SCHEDULE FOR IMMUNIZATIONS INITIATED IN INFANCY 
AGE VACCINES 



SCHEDULE FOR IMMUNIZATIONS INITIATED 
AFTER AGE ONE 



2 Months 
4 Months 
6 Months 
12 Months 
18 Months 
4-6 Years 
14-16 Years 



DTP #1,T0PV #1 

DTP #2, TOPV #2 

DTP #3, TOPV #3 

Measles, Rubella, Mumps ' 

DTP #4, TOPV #4 

DTP #5, TOPV #5 

Td (continue every 10 years) 



TIME 
INTERVAL 



First Visit 



1 Mo. Later 



2 Mos. Later 



4 Mos. Later 



6-12 Mos. Later 



At age 14-16 Years 



AGE 



1-5 YEARS 6 YRS and OLDER 



DTP#1-T0PV#1 



Measles, RubelL) 
Mumps 



DTP#2-TOPV#2 



DTP#3-TOPV#3 



DTP#4-TOPV#4 



Td (every 10 yrs.) 



Tddstl-TOPVdst) 



Measles, Rubella 
Mumps 



Td(2dSTOPV(2d) 



Td(3d)-TOPV(3d) 



Td (every 10 yrs.) 



'Rubella Vaccine should not be given to a post-menarchal girl 
without physician consultation. 



(I' 



4 



i 



160 



Entry Instructions— Immunization Annex 
1. Date; Enter numerically, e.g.. 



4. 
5. 



Date 





9 





8 


7 


4 




Month 




Year 



2. Child's Name - Print the last and first names in the boxes provided, 

starting from the left in each case. If the name should contain more 
letters than boxes on the form, print the remainder out to the side 
as indicated in the example for the registration sheet. 

3. Age: Age is included here to provide a ready reference to determine the 

irranunization requirements for this age child generally as a base point 
to subsequently determine immunizations required for a particular child. 
Enter numerically, e.g., 

(3 1/2 years old) 



Age 





1 

3 





6 




Yrs. 


Mon. 


Age 








1 






or 



(10 months old) 



YrS: Mon. 



Sex : Check the appropriate box. 

Child's Project I.D. No. : Local project number for child, if used. 
Comment : The data provided under the heading titles "Immunization", 
"Age at Screening", "Key", "Schedule for Routine Immunization" (initiated 
in Infancy), and "Schedule for Non-routine Immunizations" (Not receiving 
immunizations in infancy) are for information to assist in determining 
a specific child's requirements. The source of the information is "A 
Guide to Screening" prepared by the American Academy of Pediatrics and 
elsewhere in this handbook fully referenced. 



161 



6. 



7. 



Current Status - Routinely Required for Children this Age - Using the 
age and sex of the child being screened as the sole factors, simply 
use the appropriate age column on the form under the heading "Age at 
Screening" as the basis to check each box indicating requirements 
for specific immunizations e.g., a child is male and 



7 months old or 4 1/2 years old or 10 years old 



DTP #1 


E 








TOPV #1 


H 


m 





DTP #2 


t3 


a 





TOPV #2 


ra 







DTP #3 




m 





TOPV #3 


[3 


[3 





Measles 


□ 


Q 





Rubella 


□ 


a 





riumps 


LJ 




1 /I 


uir atter age lo no. 
(#3 or 4) 


1 — 1 
LJ 





□ 


TOPV after age 18 Mo. 
(#3 or 4) 


□ 








DTP after age 4 Yrs. 
(#3, 4 or 5) 
(Td if after 6 Yrs.) 


□ 


□ 


0-T-d 


TOPV after age 4 Yrs. 
(#3, 4 or 5) 


a 


P 





Td within last 10 Yrs. 


□ 


□ 


o 


t Status - Has Child Had 


this Immunization - 


Including Current Visit? 



Enter Date Received - Question the mother concerning the status of each 
immunization indicated as required by the previous step (paragraph 6). 
Immunization records kept by parents or recorded in a medical chart 



c 



162 



can be accepted as valid. Verbal reports by parents are less valid 
but can often be accepted as evidence of immunization. The following 
interpretations are suggested by the American Academy of Pediatrics: 

- If the parent specifically recalls that at least three "baby 
shots" were given in the first six to nine months of life, it can 
be assumed that the DTP shots were given. 

- If a parent remembers an oral polio vaccine being given, it can 
be assumed that it was given. 

- The parent's recall of a "measles" shot may indicate either a 
measles or a rubella (German Measles) immunization. Unless the 
parent is certain which one was given, both must be repeated . 

Based upon responses from the mother or records, enter the dates 
previous immunizations were given and then administer and record those 
shots that should be and were given at this visit , e.g., 

(See following page) 



mmm 



163 



(Date of Birth, November 1970 - 3 1/2 Years Old) 

Routinely Req. Has Child Had This Has Child Had This 





Tor cms 
Age Child 


immumzaiion wix 
Enter Date Reed. 


immun 1 za LI on 
Enter Date Reed. 


DTP #1 


ta 


Jan. 71 


1971 


TOPV #1 





Jan. 71 


1971 


DTP #2 





Mar. 71 


1971 


TOPV #2 





Mar._7l 


1971 


DTP #3 





May 71 


*Aug. 7, 74 


IwrV ffO 


171 


Mav 71 


*Aua 7 74 


Measles 





*Aug. 7, 74 




Rubella 





*Aug. 7, 74 


- 


Mumps 





*Aug. 7, 74 




DTP after age 18 Mo. 
(#3 or 4) 









TOPV after age 18 Mo 
(#3 or 4) 


• 






DTP after age 4 Yrs. 
(#3, 4 or 5) 


□ 







(Td if after 6 Yrs.) 

TOPV after age 4 Yrs. □ 
(#3, 4 or 5) 

Td within last 10 Yrs. □ 

*Indi eating those given at the eurrent visit 



Current Status - Subsequent Immunizations, Current Series Only (Within Four 
Months of Current Visit) - Date Required - Comparing the two previous steps 
(eolumns), whieh will have indieated the immunizations required and 



16.4 



those received in the past and the current visit, the action ^~^h1s ^ 
instance is to schedule additionalTy required immunizations by entering 
the date the Trext immunizations are due~ih the four following 
months J e.g. , 

(Date of Birth, November 1970 - 3 1/2 years old) 



Routinely Reqd. 
for this 
Age Child 



DTP #1 [7J 

TOPV #1 El 

DTP #2 [3 

TOPV #2 Q 

DTP #3 [a 

TOPV #3 [7] 

Measles , [7\ 

Rubella [7] 

Mumps [7] 

DTP after age 18 Mo. |7) 

TOPV after 18 Mo. 

DTP after age 4 □ 

TOPV after age 4 □ 

Td within last 10 Yrs. p 

♦Indicating those given at the current visit. 
Current Status - Subsequent Immunizations - Current Series Only (Within Four 
Months of Current Visit); Date Received 

Enter the date subsequently scheduled immunizations are received, e.g., 



Has Child Had this Subsequent 
Immunization Immunizations 
Enter Date Reed. 

Jan. 71 

Jan. 71 

Mar. 71 

Mar. 71 

May 71 

May 71 

7 Aug. 74* 

7 Aug. 74* 

7 Aug. 74* 

1 Oct. 74 
1 Oct. 74 



165 



(Date of Birth, November 1970 - 3 1/2 years old) 
Routinely Reqd. Has Child had this 





for this 
Aqe Child 


Immunization 
Enter Date Reed. 


DTP #1 





Jan. 71 


TOPV #1 


El 


Jan. 71 


DTP #2 


1 — 71 


Mar. 71 


TOPV #2 


ta 


Mar. 71 


DTP #3 


Q 


May 71 


TOPV #3 


Q 


May 71 


Measles 





7 Aug. 74 


Rubella 


ta 


7 Aug. 74 


Mumps 


El 


7 Aug. 74 



Subsequent 
Immunizations 
Date Reqd. 



Subsequent 
Imnunizations 
Date Reed. 



10 Oct. 74 



DTP after 18 Mos. [T] 1 Oct. 74 

TOPV after 18 Mos. |7] 1 Oct. 74 

TOPV after 4 Yrs. □ 

Td within last f"] 
10 Yrs. 

When this step is completed and the subsequent immunizations received 
match those required, the child is now completely immunized for its 
age— the status is current. At the next rescreen in the following year 
for the child used in the above example, he will require two additional 
shots (DTP after age 4 and TOPV after age 4) to be considered completely 
immunized for his age. 



16i 



L FLOWCHART 

f IMiymjiNHZWnON SUQ/SUBSVST^ 




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s 



KCONO 
VWIT 

Iran 

UMMUMI 




l&6a 



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BtWAT 
SECOND VISIT Sf OUENCE 



mi HO 

AMD 
FOUMTM 
VISITS 

nuisuN.i 




REPEAT REAmXNTMENT 
SEQUENCE 




MONTHLY ROSTEN FROM 
THE HSRI OF ALL CHILD- 
REN - NOT COM)>LETINO 
IMMUNIZATIONS IMTHIN 
120 OAVS OF INITIAL 
VISIT 



ALL CHILDREN AT THIS 
POINT (END OF Ml VISIT 
4 MONTHS FROM DATE OF 
INITIAL VISIT) SHOULD NOW 
BE COMPLETE (CURRENT FOR 
AGE) UNLESS FOR SOME 
REASON (TEMPERATURE/FEVER) 
A SCHEDULED IMMUN. WAS NOT 
AOMINISlliRED AT ONC OF 
THE SUBSEQUENT VISITS (A 
6* VISIT WAV BE NECESSAflV 
M THESE INSTANCES! 



9 




COMPLETED IMMUNIZAriONS (CHILD CURRENT FOR AGE) 



WCOMPLETEO IMMUNIZATIONS 



3 



4 




168 



PLEASE PRINT YOUR NAME AND ADDRESS IN FULL 



FIRST CLASS 
PERMIT 
NO. 



BUSINESS REPLY MAIL - no postage stamp neccesary if mailed in u.s. 



POSTAGE WILL BE PAID BY 



COUNTY HEALTH DEPT. 

P.O.BOX 



This represents the reverse side of the Problem Referral and Case Monitoring Sheet 



t 



169 



Entry Instructions— Problem Referral and Case Monitoring Sheet 

(A separate form is filled out for each problem found in screening. 
Items 1 through 9 are completed by the caseworker or screening facility.) 

Screener's Section (upper third- top section) of the Form 

1. Child's Project I.D. No. : Refer same item - Registration Sheet 

2. Date : 

3. Child's Name ; 

4. Sex: " " 

5. Child's Birthdate : 

6. Parent's Social Security No. : " " " " " 

7. Child's Medicaid No. : " " " " " 

8. Practitioner's Address : Type, print, or write in the name and mailing 

address of the practitioner to whom the patient is being referred for 
the respective problem. 

9. Problem History : 

a. Check only one of the three options 

I I Completely new to child's caretaker 
I I Previously known, but not under care 
i I . Previously Ofider' care 

If this information is not obtainable, leave all these boxes blank. 

A problem that is completely new to the child's caretaker (mother) 
would be something like a heart murmur that had not been previously 
detected . 

A problem that is "previously known but not under care" would 
be one known but apparently not considered sufficiently serious by 
the parents to warrant professional (practitioner's) care . 



t 



170 



"Previously under care" means that it was known and had been 
under the care of a professional practitioner. 

b. Reason for Referral : Enter the disease/injury category and number from 
the screening sheet for which the problem was initiated, e.g., pinworms, 
diabetes, anemia. 

c. Major I CPA Category : Enter the six digit broad ICDA range from the 
screening sheet covering the problem for which referred, e.g., for 
pinworms, the major ICDA category is "000-136"; for diabetes, it is 
"240-279"; for anemia, it is "280-289", etc. 

PRACTITIONER'S (OR STAFF'S) SECTION (MIDDLE THIRD-MIDDLE SECTION) OF THE FORM 

(Items 1 through 8 following the statement in middle third of form "PLEASE 
ANSWER THE FOLLOWING QUESTIONS AND RETURN IN THE MAIL" are completed by the 
practitioner (or his staff) to whom the child was referred.) 

Examination Date : Enter numerically, e.g., 

09 08 75 

Month Day Year 

The date of examination is important in ultimately providing time lapse 

studies between the dates of screening, examination (diagnosis) and complete 

problem resolution. A factor for evaluation is to determine whether excessive 

time lapses between these three reference points has an impact on completion 

rates and kept appointments. 

1. Do you confirm the existence of a health problem? ( | Yes |~I No If no, 

return this form as indicated . 

Check "Yes" or "No" as appropriate. 

The purpose of this question is to confirm or deny the existence of a 
problem and identify false positives (falsely declared suspected unwells). 




I 



171 




Rates of false positives will relate to the response to this question. If 
the practitioner checks "No" in this instance, the form requires no further 
entry by the practitioner or his staff and the form should then be folded 
as indicated and mailed. 

2. If "yes" to No. 1, is it the same for which referred? | | Yes f 1 No 

The purpose of this question is to provide a basis for evaluating the 
accuracy of the screening activity in identifying the "health problem" 
categorization. The secondary purpose, in connection with question 3, is to 
establish the correct problem identification for which the child was referred 
for future reference and for statistical tabulation (incidence rates, etc.) 

3. If "no" to No. 2, what diagnosis is determined? 



If "no" to question No. 2 was checked, the practitioner should enter 
his designation of diagnosis along with the three digit ICDA code for that 
diagnosis (if ICDA code identifiers are used in his office). 

The purpose of the diagnostic identification and related ICDA code in 
this instance is an effort to establish a linkage between the EPSDT program 
and the respective States' Medicaid Management Information System to alter- 
nately determine diagnostic and treatment costs associated with the program 
through either a scheduled computer program or hand sampling of Medicaid 
data. The linkage between EPSDT and Medicaid (without MMIS - EPSDT subsystem) 
is the practitioner billings for services that can then be related by the 
child's name. Medicaid number, time relationship between the screening and 
problem referral and the billing, and the diagnostic correlation (label and 
number). The latter is predicated upon the assumption that the practitioner's 



Major ICDA Code Q 



] (If used in your office) 



172 



three digit coding will correlate (fall within the parameters of) the 
broader six digit range as indicated by the screening activity on the first 
third of the Problem Referral and Case-Monitoring Sheet. 

Since MMIS - EPSDT subsystems do not yet exist in most State juris- 
dictions, the foregoing somewhat imperfect linkage is nevertheless the most 
feasible, on an interim basis, upon which to directly relate diagnostic and 
treatment costs to specific children and conditions in an EPSDT demonstra- 
tion. It requires agreement with the managers of the MMIS at the inception 
of the demonstration relationship (HSRI - Demonstration jurisdiction and 
SRS/DHEW) to provide such cost data as related to specific rosters of 
children, or to permit access of specified demonstration personnel to 
appropriate Medicaid tapes to extract the cost data. 

Is the diagnosed condition (item 3) Chronic 1 j or Acute | 1 Symptomatic [ j 
or Asymptomatic | | 
The practitioner should check all boxes that apply. The absence of a 
check mark is significant. One check should apply to each pair. 

These data are intended to particularly identify chronic and acute 
conditions being treated and costs related to these two classifications of 
conditions. Secondly, a major factor of program effectiveness should be 
the rate of conversion of chronic conditions to well /inactive through 
treatment programs. Thirdly, another major factor of program evaluation 
should be the rate of chronic conditions brought to "resolution". 



173 



5. Is the diagnosed condition? (check on scale YOUR evaluation) 

1 2 3 4 5 
mild moderate severe 

The practitioner is requested to circle or line through the number that 
best fits his estimate of the problem's seriousness. If it is a hernia, for 
example, is it mild, moderate, or severe? If severe, the implication might 
be that immediate remedial action is required. If less than serious, the 
implication is that remedial action may be deferred. 

Most significantly, this is intended to be an outcome measurement of the 
impact of the EPSDT program on the severity of conditions found in children. 
It relates most specifically to the changes in conditions categorized by the 
practitioner as severe over time. If EPSDT is an effective program, the 
percent of severe conditions found, particularly in rescreens, should decline 
over time. This assumes that the program has been successful through treatment 
in either eliminating the problem, or modifying it to a moderate or mild 
category. 

An additional evaluation effort will be to relate specific diagnostic 
conditions to severity and the response of these conditions through treatment 
to reflect reduced severity. Some type of program priority, by condition, 
for example, could well be an outcome of this analysis, particularly when 
related to associated costs. 

--Problem Resolution or Status-- 

6. Is the condition resolved this visit? ( 1 Yes | 1 No 

The practitioner (or staff) should check "yes" or "no" as appropriate. 

7. If "yes" to No. 6, in what manner? (check one) 

a. Condition minor— treatment completed; condition now cured or inactive | j 



174 

b. Condition presumed cured or Inactive within 10 days of this 

visit with treatment prescribed [J 

c. Condition noted, treatment (or further treatment or coun- 

selling) not advisable or warranted []] 

The practitioner should check one of the three above options (a, b, 
or c) if the answer to question 6 was "yes". 

One of these three options should cover virtually all circumstances 
under which a condition (problem) would be resolved on a one-visit basis. 
Most "acute" conditions will probably be resolved within the options 
indicated. In the main, this category of options will "close" the 
problem for the case monitor. 
8. If "no" to No. 6, what is the circumstance? (check one) 

a. Remains under treatment (this office/clinic) 

b. Referral to other practitioner for diagnosis or treatment as indicated 

Specialty 

Specific practitioner suggested 

c. Condition noted, but not treated or referred, because: 

(1) Treatment not authorized by State plan | | 

(2) Treatment not locally available ] [ 

The practitioner should check one of the three above options if the 
answer to question 6 was "no". 

One of these three options should cover virtually all circumstances 
under which a problem would not be resolved on a one-visit basis. Some 
acute and most chronic conditions will probably fall within these three 
options. These options indicate a continuing activity for the case monitor 
in this case following the examination episode. The case monitor will have 
to maintain contact with the examining practitioner or clinic if continuing 
treatment option 8a is indicated, until the problem is appropriately 



r 



I 



m 



17E 



resolved. 

If option 8b is indicated by tbe examining practitioner/clinic, the 
case monitor will need to ascertain what specialty referral is required 
(if not indicated in the space provided), make an appropriate appointment, 
originate a new problem referral sheet, and follow the case to appointment 
contact and treatment completion. 

If circumstance 8c (1) or (2) is indicated by the examining practi- 
tioner/clinic, the case monitor will need to ascertain whether an exception 
should be requested and, if indicated by consultation with appropriate 
health counterparts, initiate and follow up on such a request. 
UPON COMPLETION OF THE APPROPRIATE ENTRIES IN THE MIDDLE SECTION OF THE 
PROBLEM REFERRAL AND CASE-MONITORING SHEET, THE PRACTITIONER (STAFF) SHOULD 
FOLD THE FORM IN THIRDS AS INDICATED, SEAL, AND MAIL (ADDRESSED AND FRANKED). 
CASE MONITOR'S SECTION (LOWER THIRD) OF THE FORM 

This section comprises the case monitor's means for "management control" 
of the problem until resolution, termination or time lapse. 
1 . Was the child's initial appointment with the practitioner kept? 

a. First appointment I i 

b. Reappointed - 2nd appointment I J 

c. Reappointed - 3rd appointment | j 
(If "no" on 3rd appointment, go to 4a(l)) 

This question is a means whereby the case monitor will maintain manage- 
ment of the problem from screening, wherein a problem would have been sus- 
pected and a problem sheet initiated, to the making of an appointment for 
the child for diagnosis and treatment of the suspected problem and to the 
actual point of "appointment kept" with the designated practitioner/clinic. 



/ 

[ 



111 



i 



( 



176 



The child's caretaker will be provided the appropriate copy of the 
Problem Referral and Case-monitoring Sheet , directly at completion of 
screening or by mail at completion of screening, for hand carrying to the 
designated practitioner/clinic with whom the appointment has been made by 
the case monitor or screening activity, depending upon local arrangements. 

Should the first appointment not be kept, the case monitor will note 
this by checking "no" to la, arrange for a reappointment (second appointment) 
Simultaneously, the case monitor will ascertain the problem that precluded 
the first appointment from being kept and attempt to circumvent any resolv- 
able obstacle for the second appointment. Should the second appointment for 
the problem not be kept, a similar notation will be made by checking "no" 
to lb, and appropriate procedure, as previously indicated, followed. A 
third appointment will be made and if this is also not kept, the case will ba 
closed with the assumption that the family is declining to participate 
further in the program. The case monitor will then check 4a(l), fill in 
Items 5 through 9, and mail the appropriate copy of the sheet to the 
Health Services Research Institute. 

(Only one of item 2, 3, or 4 (following) will pertain.) 

2. Problem Resolved (check one) : 

a. Condition minor; treatment completed 1st visit, now cured or 

inactive (Ref. item 7a) [ | 

b. Condition presumed cured/or inactive within 10 days of 1st 

visit under treatment prescribed (Ref. item 7b) | j 

c. Condition noted; treatment not advisable or warranted 

(Ref. item yc) Q 

d. Treatment plan completed, now cured or inactive (follow up 

contact with practitioner or parent) | | 

e. Treatment terminated; maximum benefit achieved (not necessarily 

inactive or cured) ( follow-up contact) 

If the problem is resolved within 180 days of the problem sheet being 
initiated (date in upper right corner of the problem referral sheet). 



fl 



( 'I 



177 



the case monitor will check the appropriate (applicable) method of resolution 
(2a, b, c, d, e), fill in items 5 through 9, and mail the appropriate copy 
of the sheet to the Health Services Research Institute. TKe case monitor 
will ascertain the applicable method of resolution, either through receipt 
of completed copies of the Problem Referral and Case-monitoring Sheet from 
the practitioner (one visit complete sequence— practitioner's items 7a, b, 
or c), or through follow-up contacts with the appropriate practitioner or 
the child's parents, for cases requiring referral or more prolonged treat- 
ment (practitioner's items 8a or b). 
Problem not resolved (check one) : 

a. Still under treatment (original practitioner/clinic) 

(Reference item 8a) [ I 

b. Still under treatment (referred practitioner/clinic 

(Reference item 8b) \ \ 

c. Condition noted, but not treated, due to: 

(1) treatment not authorized in this jurisdiction \ I 

(Reference item 8c(l)) 

(2) treatment not locally available (Ref. item 8c (2)) | | 

If a problem is not resolved (options in item 2, this section) or 
otherwise terminated (options in item 4, this section) within 180 days of 
the problem sheet being initiated , the case monitor will check the 
appropriate item above (3a, b or c), fill in items 5 through 9, and mail 
the appropriate copy of the Problem Referral Sheet to the Health Services 
Research Institute. The case monitor will continue to monitor the case 
from her copy (copy 2) of this sheet. The case monitor will receive a 
roster (by name) from the Health Services Research Institute each two 
months of those problem sheets received at the end of 180 days for whom 
no resolution was indicated. The case monitor will indicate next to each 



\ I 



178 



name the current status of the case, i.e., "Treatment plan completed, now 
cured or inactive", "Treatment terminated-maximum benefit achieved", 
"Still under treatment", and return the roster to the Health Services 
Research Institute. 

4. Other problem termination (check one) 

a. Family declines further participation 

(1) Failure on third appointment for first visit (Ref. item 1) | | 

(2) Failure on third appointment for extended treatment 

(Follow-up with practitioner or parent) | | 

b. Family moved from jurisdiction (Follow-up contact or records) ^ 

c. Family no longer program eligible (Follow-up contact or 

records) | | 

It is assumed that, in the main, these problem termination options 
will occur prior to 180 days following initiation of the Problem Referral 
Sheet. This is particularly true of item 4a and the item will be checked 
by the case monitor as applicable, items 5 through 9 completed, and the 
appropriate copy of the sheet mailed to the Health Services Research 
Institute. It will also probably apply to items 4b and c, except in those 
instances in which the case monitor, in following up on items 3a or b of 
this section above, finds that the child's family has moved or is no 
longer eligible. In these cases, the problem will be terminated at the 
180 day checkpoint, but with the appropriate option checked (4b or c) by 
the case monitor and items 5-9 completed and the form mailed to Health 
Services Research Institute. 

5. Source of information for entry in 2, 3, or 4 above: 

a. Practitioner | | b. Practitioner's staff | | c. Child's 
parent | | d. Other (specify) 



( 



( 



i 



179 



6. Primary method of follow-up for entry in 2, 3, or 4 above : 
a. Mail | | b. Phone | [ c. Personal contact t I 

d. Other (specify) 

Items 5 and 6 are intended to provide evaluative information regarding 
the most productive and most frequently utilized methods by which case 
monitors maintain successful surveillance of their cases to achieve various 
rates of case completions and corresponding costs. The case monitor will 
enter the source of information (5a, b, c or d) which provided the informa- 
tion that resulted in the actual entry in item 2, 3 or 4. Generally, this 
will be the last contact made that resulted in the entry. 

This same guidance is applicable to item 6; it will relate to the 
means utilized to obtain the information for the entry in items 2, 3 or 4. 

7. Current status of case (if multiple problems identified) 

a. Problems identified (problem sheets originated) 

(circle one) 1 2^ 3 4 5 

b. Problems resolved or terminated as of date this form completed 

(circle one) 12 3 4 5 

This entry relates to the child as a whole; as a case rather than a 
problem, in terms of single or multiple problems identified . It is a double 
check for the case monitor to maintain cognizance of multiple problems 
and not close a case out simply because a single problem was resolved. 

In completing item 7 at the time of completion of a problem sheet 
pertaining to a child (a resolution or terminating entry in items 2, 3 or 
4, this section), the case monitor will record the total number of problem 
sheets originated on the child at the time of screening, e.g., if two 
problems had been identified at screening and confirmed by diagnosis, the 



(ff 



( 



180 



entry would appear as 

"7. a. Problems identified (problem sheet originated) 
(circle one) 1 (g) 3 4 5 

If, at the time of this problem resolution there was still one 

problem for this case unresolved or unterminated, the second line would 

appear as 

"7. b. Problems resolved or terminated as of date this form completed 
(circle one) ® 2 3 4 5 

8. Ski 11 /or professional quality of case monitor 

a. Nurse (PHN or other RN) | | b. Social worker | | 

c. Clerk/administrator | | d. Other (specify) 

This entry is intended to identify the skill or professional level 
category of the case monitor. The entry is significant since, in many 
demonstrations, the evaluation of the case-monitoring subsystem will relate 
to the productivity and costs of case monitors with varying (and controlled) 
qualifications. 

9. Date form completed 

Month Day Year 

The case monitor should enter the date in item 9 on which information 
is obtained to make the entry in items 2, 3 or 4, this section, indicating 
case resolution or termination, and the completion of items 5 through 8 is 
accompl ished. 



SPECIAL INSTRUCTIONS TO CASE MONITORS WHEN PRACTITIONERS REFER PATIENTS TO OTHER 
PRACTITIONERS FOR DIAGNOSIS OR TREATMENT 

In the event a Problem Referral Sheet is received by the case monitor from 



181 



a practitioner indicating referral to one or more specialists, the case monitor 
needs to (1) ascertain to which practitioners (specialists) the case should be 
referred, (2) arrange the appropriate appointments, if necessary, (3) originate 
a new (additional) problem referral sheet for each of the new practitioner 
referrals, and (4) assure that the child's caretaker is provided a copy of the 
new Problem Referral Sheet to hand carry to the referred practitioner and is 
aware of the specifics of the new referral. 

The new Problem Referral Sheet should be initiated by the case monitor in 
accordance with the earlier instructions as to the preparation of the form, 
except for the following: 

Item 1 : Child's Project I.D. Number 

Assure that the same number is used as in item 1 on the original 

Problem Referral Sheet . 

If overprint or stamped document control numbers are used on the forms in 
this project in addition to the child's Project I.D. Number, the case monitor 
must blank out the control number printed on the new Problem Referral Sheet 
and write in the control number from the original problem sheet. This action 
is essential to case-monitoring in the computer system used by the Institute. 



( 



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182 



ANNEX A 

Normal Ranges for Vital Signs, Tests and Measurements and Gross Medical History 
and Physical Examination Indicators of Specific Disease and Injury Conditions " 

This annex contains criteria for estimating the "normal /abnormal " findings 
of certain vital signs, tests and measurements, as well as other indicators of 
disease and injury normally found through physical examination and family and 
child histories. The annex is in three parts as follows: 

*Part I - Basic Measurements and Vital Signs 

*Part II - Tests 

Part III - Focus of History Taking and Physical Examinations Pertaining 
to 38 Disease/Injury Categories 

Consistency of findings of "normal" and "abnormal" and of conditions and 
rates of conditions found between demonstration projects is dependent upon the 
use of these standardized norms. In the development of this annex, considerable 
reliance was placed upon "A Guide to Screening for the Early and Periodic 
Screening, Diagnosis and Treatment Program (EPSDT) under Medicaid" developed 
by the American Academy of Pediatrics (Frankenburg, William K. , M.D., and 
Worth, Frederick A., Jr., M.D.) under Contract SRS 73-31, Social and Rehabili- 
tation Service, U.S. Department of Health, Education and Welfare, June 1974. 

These "norms" and medical history and physical examination gross indicators 
are also provided to assist paramedic type screeners to determine the presence 
of a suspected abnormality and health problem. 

*Parts I and II were compiled by: 
William Weston III, M.D. 

Associate Professor of Pediatrics (Greenville) 
Department of Pediatric Education 
Medical University of South Carolina 
Greenville, South Carolina 29602 
formerly of The University of Texas Health Science Center, San Antonio, Texas 



(( 



183 



If a "screener" receives a report, for example of a hematocrit on a 
child which is not within the range of normal contained herein, he will 
check an abnormal in that column opposite the TEST listing HEMATOCRIT 
on the line (08) of the screening sheets When considering the initiation 
of a problem sheet (right column) the screener will be greatly influenced 
by this "abnormal" entry pertaining to a possible "anemia" (Problem No. 08). 

If a screener, during a physical examination, notes a generalized 
skin rash. he may make an entry check (/) of abnormality suspected under 
PHYSICAL EXAMINATION AND OBSERVATION dn line 32 (Problem No„ 32) or 
line 03 (Problem No. 03). If he also notes and records an abnormal TPR 
he may be inclined to originate a problem sheet and so check in the right 
column on line 03 (BACTERIAL INFECTIONS). 

The screener is not making a diagnosis. He/she is attempting to 
identify a suspected problem for referral to a physician (referral sheet) 
for diagnosis and treatment. The method employed here is to force the 
screener to consider, in a logical sequence, family and child history, 
tests and vital signs, and physical examination and observation in arriving 
at a conclusion as to whether a problem sheet should be originated relative 
to 38 conditions coimon to children and having a high potential for chronicity 
in later life. 

*If the Project has a "retest" policy for all initial abnormal test 
findings this entry would not be made u ntil confirmed by retest. 




( 



184 



NORMAL RANGES - BASIC MEASUREMENTS AND VITAL SIGNS 



(All item references are to the Screening Sheet) 
1. Height (Item 12) * 

Boys 



>> 
-o 



O) 

s- 



Girls 



Age 


Min. 


Max. (Inches) 


Min. 


Max 


Months Birth (Length) 


18 


22 


18 


22 


3 


22 


25 


22 


25 


6 


25 


27 


24 


27 


9 


26 


29 


25 


29 


12 


28 


33 


27 


32 


18 


30 


36 


29 


34 


24 (Erect) 


31 


38 


30 


37 


Years 3 


35 


41 


33 


41 


4 


37 


44 


36 


44 


5 


40 


47 


38 


48 


6 


41 


51 


40 


51 


7 


43 


53 


42 


54 


8 


45 


56 


44 


57 


9 


47 


59 


47 


60 


10 


49 


60 


49 


63 


11 


51 


63 


50 


66 


12 


53 


67 


52 


68 


13 


53 


70 


53 


70 


14 


57 


72 


56 


71 


15 


58 


73 


57 


71 


Guide to Screening for 


the Early and Periodic Program (EPSDT) 



developed by the American Academy of Pediatrics (Rrankenburg, William K., M.D., and 
Worth, Frederick A., M.D.) -Page 134. 



Height (Continued) 

Age 
16 
17 
18 
19 
20 
21 

2. Weight (Item 12)* 
Age 

Months Birth 
3 
6 
9 
12 
18 
24 

Years 3 
4 
5 
6 
7 
8 
9 
10 




Boys Girls 



Min. 


Max. 


Min. 


Max. 


60 


74 


57 


72 


61 


78 


57 


72 


61 


78 


57 


72 


61 


78 


57 


72 


61 


78 


57 


73 


61 


78 


57 


73 


Min. 


Max. (Lbs. ) 


Min. 


Max. (I 


5 


10.5 


5 


10 


10.5 


17 


8 


14.5 


13.5 


22 


11.5 


19.5 


16.5 


27.5 


14.5 


22.5 


17 


28.5 


16.5 


26 


19 


33 


17.5 


28 


20.5 


38 


20 


31.5 


24.5 


43 


23 


37 


27.5 


45 


27 


42 


30 


50.5 


30.5 


47.5 


34 


60 


33 


62 


38 


71 


38 


66 


41 


77 


41 


93 


45 


103 


46 


103 


52 


95 


47 


99 



.) 



*See page 134, Screening Guide, for procedure. 



Weight (Continued) 

Boys Girls 



Age 


Min. 


Max. 


Min. 


Max. 


11 


57 


120 


50 


135 


12 


55 


145 


55 


150 


13 


60 


155 


59 


145 


14 


81 


175 


71 


155 


15 


79 


215 


80 


175 


16 


93 


205 


90 


165 


17 


97 


200 


85 


175 


18 


100 


200 


90 


175 


19 


110 


210 


90 


175 


20 


115 


215 


90 


175 


21 


120 


220 


100 


180 


Head or Crown* (Item 12) 










Age 


Min. 


Max. 


Min. 


Max. 


Months Birth 


33 


37 


32.5 


36.5 


1 


35 


39 


34.5 


38.5 


2 


37 


40.5 


36.5 


40.5 


3 


38.5 


42 


38 


42 


6 


42 


46 


40.5 


45 


9 


43.5 


47.5 


42.5 


47 


12 


44.5 


49.5 


43.5 


48.5 


18 


46 


51 


45 


50 


Years 2 


47 


52 


45.5 


51 


3 


48 


53 


46.5 


52 


4 - 21 


48.5 


57 


47 


55.5 



*Fronto-occipital circumference in centimeters. To convert to inches, 
multiply by 0.4. 




I 

V 



18/ 



5. 



Temperature (Item 12) 


Low 


High 


Rectal 


98 


100.2 


Oral 


97 


99.4 


Pulse* (Item 12) 






Age 


Range 
Minimum Maximum 


Birth 


110 


200 


Months 3 


100 


180 


6 


100 


172 


9 


100 


168 


12 


90 


150 


Years 2-4 


60 


140 


5-7 


60 


130 


8-10 


56 


120 


11 - 15 


52 


108 


16 - 21 


48 


100 


Respiration* (Item 12) 
Age 


Range 
Minimum Maximum 


Birth 


30 


80 


Months 3 


30 


60 


\j 


30 


60 


9 


20 


40 


12 


20 


40 


Years 2-4 


20 


30 


5-7 


20 


26 


8-10 


16 


22 


11 - 15 


15 


20 


16 - 21 


14 


20 



*During physical examination 



/ 



> 1 



( 



188 



7. Blood Pressure* (Item 12) 



Male and Female 



Age 



Years 2 
5 
8 
11 



14 
16 



4 
7 

10 

13 



Range 



Minimum 
( Systol ic ) 
(Diastol ic) 

70/30 

70/30 

80/40 

90/50 



Male 



Minimum 
15 90/50 
21 100/50 



Maximum 
140/90 
160/90 



Maximum 
( Systolic ) 
(Diastolic) 

110/70 

120/76 

124/80 

130/80 



Female 
Minimum Maximum 



90/50 
94/50 



130/80 
140/90 



*During physical examination in supine position. Cuff size 
(6, 10 and 14 cm) varies with age and size of child. Cuff should cover 
between 1/2 and 2/3 of upper arm. 

Systolic recording represents initial sound and diastolic recording 
represents disappearance of sound. Record in 2 mm. increments. 



References and Additional Reading 

1. Habicht, J. et al . Height and Weight Standards for Preschool Children. 
The Lancet , 1:611, 1974. 

2. Bayley, N. Growth Curves of Height and Weight by Age for Boys and Girls, 
Scaled According to Physical Maturity. Journal of Pediatrics , 48:187,1956. 

3. McCammon, R. (ed.) Human Growth and Development. Springfield, Illinois, 
Charles C. Thomas, 1970. 

4. National Center for Health Statistics. Vital and Health Statistics . PHS 
Pub. No. 1000-Series 11, Nos. 104, 124, 135. Public Health Service, U.S. 
Government Printing Office, Washington. Sept. 1970, Jan. 1973, Dec. 1973. 

Author's Note : These height and weight standards account for normal variations 
in the tempo of growth. The values listed are between 2 and 3 standard deviations 
from the mean for age and sex. 



( i 



189 



TESTS 

8. Tuberculin Test* (Item 23) 

Interpretation of skin tests: In all instances, only induration--sweninq 
that can be felt--or vesiculation are meaningful. Redness without 
induration is discounted. 

Diameter of Induration 

Mantoux Multiple Puncture Test 

Test (Tine, Heaf, Monovac) 

<5 mm <2 mm 

5 - 9 mm >2 mm 

>10 mm vesiculation 



(Normal) Negative reaction 
**(Below)Doubtful reaction 
***(Abn) Positive reaction 

9. Urinalysis (optional) 



Specific gravity 
Microscopic - WBC 
Microscopic - RBC 



Glucose 

Protein 

Acetone 

Blood 

PKU 

10. Urine Culture**** 



(Normal) Negative 
(Abnormal) Positive 



Normal Range 

1.002 - 1.0028 
£ 10 per HPF 
<_ 5 per HPF 

Result 

Negative 
Negative 
Negative 
Negative 
Negative 



Colonies per ml of urine 

Dip Slide Test (absence of symptoms) 

< 99,999 

>_ 100,000 of same organism in three 
consecutive urine cultures 



*See page 156, Screening Guide 

**An persons with doubtful reactions by multiple puncture tests should 
be retested with Mantoux. 

***Individuals with history of BCG vaccination, use >^ 15 mm. ^ 

****See page 163, Screening Guide for procedure 



( 



190 



11. Hematocrit (Hemoglobin) (Item 23) 



Male and Female' 



Age 

Normal : 2-5 days 

2 mos. - 2 years 
3-10 years 



13-17 years 
18-21 years 



13-17 years 
18 - 21 years 

Abnormal: If less than indicated above 



Hematocrit 
value (%) 

> 44 
1 32 

> 36 



Males 



> 38 

> 42 



Hemoglobin 
value (gm %) 

> 15 

> 12 



> 13 

> 14 



Females 



> 36 

> 38 



> 12 

> 13 



12. Sickle Cell (Item 20) 

(Normal) Negative Hemoglobin electrophoresis = AA 

(Abnormal) Positive Hemoglobin electrophoresis = SA - Trait 

SS - Anemia 

SC - Disease 

SF - Disease 

S alone or with "^AA&F-Disease 



F = Fetal hemoglobin"^ 



Age % of total hemoglobin (normal) 

Birth 50 - 55 

1 year < 15 

1 - 2 years < 5 
2-3 years < 2 

13. Denver Developmental 

A. Inventory - consult accompanying literature for interpretation of 
responses. 

B. Screening test - consult manual for age standards. 
Report borderline or subnormal as suspect problems. 

14. Other Developmental - Specify 

Efforts should always be made to use culture-fair procedures. 

A. Questionnaire - Consult accompanying literature for interpretation of 



i 

r 

( 



( 



191 



responses. 
B. Test - consult manual for scoring. 
Report borderline or subnormal as suspect problems. 

15. Vision 

A. Snellen or Titmus 

Age Visual acuity 

Normal /pass: Birth - 1 year* 

2-9 years 20/40 
10-21 years 20/30 

Abnormal /fai 1 : If less than above in either eye 

B. Hirschberg (Corneal light reflex) or alternate cover test for muscle 
imbalance 

Result 

Normal /Pass or absent No deviation of either eye 
Abnormal /fail or positive Deviation of one or both eyes 

C. Other (Specify) 

16. Hearing 

A. Questionnaire** 

B. Calibrated Noisemakers 

Age Stimuli Normal Response (Pass) 

Birth-3 mo. Startle, e.g., hand clap Demonstrate Moro Reflex 

4 mo-7 mo. Voice and noisemaker at^ Show one of 15 different responses, e.n. 

six feet recognition, smile, extend arm toward sound 

8-12 mo. Voice and noisemaker at^ Full right angle turn of head, neck and 
six feet torso toward side from which sound comes 

13 - 24 mo. Voice and/or noisemaker Body movement and/or vocal expression 
outside visual field that sound is received. 

Abnormal /Fai 1 : If less than indicated above. 

*See page 113, Screening Guide 
**See pages 131-132, Screening Guide 



f 

( 



{ 



192 



C. Audiometer 

Age Normal Response (pass) 

3-5 years 25 dB at 1000, 2000, 4000 Hz 

6-11 years 25 dB at 500. 1000, 2000, 4000 Hz 

12-21 years 25 dB at 500, 1000, 2000, 4000, 6000 Hz 
Abnormal /Fai 1 : Failure to respond at any two frequencies (Hz) for 
either ear. 

D. Impedance Bridge 

Age 2-21 years - See following graph and table 



193 



IMPEDANCE BRIDGE 



Recording 

Type Stapedial 4000 Cycle 
TympanOgram Reflex-90 dB 25 dB (Sensorineural) 



A 
A 
A 
B 
B 
B 
C 
C 
C 
C 



+ 
+ 



+ 
+ 



+ 
+ 
+ 



Interpretation^ * , includ- 
ing recommended referral 
in parentheses below 

Normal 
Normal 

Abnormal (Audiologist) 

Abnormal (Physician) 

Abnormal (Physician) 

Doubtful - Repeat 

Ambiguous (Advise physician) 

Abnormal (Physician & audio- 

looist) 

Abnormal (Physician X audio- 
logist) 
Abnormal (Physician) 



TYMPANOGRAMS 



Normal 


= A 


Immobile 


= B 


Retracted 






194 



17. Phonocardioscan - Consult manufacturer's literature for abnormal 



readings. 



18. Lead* 



Test 



Normal Values 



A. FEP (Free Erythrocyte porphyrin) 



< 59 ug/ML 
of whole blood 



B. Blood Lead** 



< 30 ug/ML 
of whole blood 



References 

1. The Tuberculin Test; American Academy of Pediatrics Committee Report. 
Pediatrics 54:650, 1975. 

2. National Center for Health Statistics. Vital Health and Statistics 
PHS Pub. No. 1000-Series 11, No. 146 Public Health Service, U.S. 
Government Printing Office, Washington, December, 1974. 

3. Normal Values for Pediatric Clinical Chemistry; American Association 
of Clinical Chemists Preliminary Committee Report. Ross Laboratories, 
Columbus, Ohio. August, 1974 

4. Hardy, W,, et al . Auditory Screening of Infants, Annals of Otology, 
Rhinology and Laryngology 71.2:759, 1962. 

5. Cooper, John. Personal communication - University of Texas Health Science 
Center. 

^' Reigart, R. Personal Communication - Medical University of South Carolina, 
Charleston, South Carolina. 



*See page 188, Screening Guide for identification process 
*Requires laboratory with demonstrated quality control. 



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204 



X. PROGRAM OF INSTRUCTION FOR SCREENERS IN USE ^ FORMS, NORMS AND GROSS 
INDICATORS 

Paramedic screeners should undergo a 40 hour course Cif instruction 
to prepare them to complete the screening form by taking or integrating 
family and child histories, interpreting tests and measurements and 
performing a physical examination. The objective is to make a determina- 
tion as to whether or not to initiate a problem sheet (referral to a 
physician) in 38 specific disease/injury categories with a minimum 
(10% or less of falsely declared wells or falsely declared unwells). 

The course of instruction should cover the following instructional 
material. 



When complete this section will include lesson plan outlines for each hour 

of Instruction - concept of supporting training aids (slides, film strips, charts, 

models, etc.), practical exercises and tests. 



205 



Hours 

EPSDT - Its Purposes and Objectives 3.0 
Demonstration project - relationship to program 
This project - its goals & objectives 
Subsystems of EPSDT 
Common Data Base 

Primary Indicators of Effectiveness 
Testable Hypotheses 

Local Data Collection - How accomplished. 

Forms (General explanation; EPSDT Registration 

Sheet, EPSDT Screening Sheet and EPSDT Problem 

Referral and Case Monitoring Sheet) 

Sub-Total 370" 

Body Systems & ICDA Major Classifications of 
Disease and Injury 

ICDA (General - Purposes, Use) .5 

38 Disease and Injury Categories utilized in 

demonstration system .5 

Body Systems & ICDA Major Classifications 8.0 
(Relate to Screening Form) (Definitions and 
Major Conclusions) 

Infective & Parasitic Diseases 
Neoplasms 

Endocrine, Nutritional & Metabolic Disorders 
Diseases of Blood & Blood Forming Organs 
Mental Disorders 

Diseases of the Nervous System, Sense Organs 
Diseases of the Circulatory System 
Diseases of the Digestive System 
Complications of Pregnancy, etc. 
Diseases of the Musculoskeletal System and 

Connective Tissue 
Congenital Anomalies 

Causes of Perinatal Morbidity & Mortality 
Symptoms & 111 -Defined Conditions 
Accidents, Poisonings & Violence 

Sub-Total 9.0 



206 



Hours 



Vital Signs 



4.0 



Height) 
Weight) 
Crown Size) 
Temperature) 
Pulse) 

Respirations) 
Blood Pressure) 



What they are. 
Norms . 

What abnormalities 
may signify in 
arriving at problem 
determination. 



Sub-Total 



Tests 



4.0 
3.0 



Pinworm 
TB 

Urine culture 
Urinalysis 
Hematocrit 
Hemoglobin 
Sickle cell 
Denver Developmental 
Vision - Snellen, Titmus, etc. 
Hearing - Audiometer, 
. Impedance Bridge 
Phonocardioscan 
Lead 



What they are. 
Norms 

What abnormalities 
may signify in 
arriving at 
problem 
determination. 



Histories 
Family) 
Child ) 

Physical Examination 



Head 
Trunk 

Extremi ti es 

Genitalia 

Skin 



Sub-Total 



What they signify 
in arriving at 
problem determination 

Sub-Total 



What to look for. 
What abnormalities 
may signify 
in arriving at 
problem determination 



3.0 
2.0 



2.0 
2.0 



Sub-Total 



2.0 



207 



Hours 

Child's Healthiness Rating - Significance and .5 
How to use 

Sub-Total 75" 

Immunizations 2.0 

General - Purpose of 

DTP ) Historical significance 
DT ) Schedule for administration 
Polio) 

Sub-Total 2T0~ 

Practical Exercises in Screening, Problem Deter- 
mination & Form Completion 14.5 

(Registration, Screening, Problem Referral) 

Sub-Total 14.5 

Total 40.0 



4 



208 



DATA PROCESS IN G INSTRUCTIONS 

A. General 

1. This section will primarily identify the distribution and timing 
of copies of the various data input sheets and provide guidance 
relating to internal data processing controls to assure the validity 

of the data sought. This section more than any other of the 
manual will require significant elaboration and tailoring when 
applied to specific projects. 

2. Overprinted Document Control Numbers for Problem Referral Sheets 

A sequential numerical stamp will be used to overprint all 
problem referral sheets so that each set (copies 1 through 5) of 
the problem sheets has its unique number. 

In those instances inwhich a practitioner indicates further 
referral, the case monitor will initiate a second problem referral 
sheet, modified to reflect the same number as the original 
referral sheet, e.g., 345, but with an added saffix such as .1, 
e.g., 345.1. This procedure will apply to any number of referrals 
relating back to an original problem referral sheet, with sub-- . 
sequent suffixes such as 345.2^, 345. _3» etc. 

B. Registration Sheet 

1. Copies prepared: 3 

2. When prepared: At registration 

3. Who prepares: Caseworker 



209 



4, Distribution: . Copy 1 - Registration activity (record copy) 

Copy 2 - Screening activity (accompanies screening 
, * sheet) 

Copy 3 - Institute (at time of preparation) 
EPSDT Family Contact and Screening Appointment Card 

1 . Copies prepared: 4 

2. When prepared: At time case-finding aide makes initial face- 

to-face contact with eligible family head of 
household 



3. Who prepares: 

4. Distribution: 



Case-finding aide 

Copy 1 - Case-finding aide , working copy 
Project record copy 



Copy 2 
Copy 3 



Institute (at time of completion of 
initial interview with head of 
household ) 



4 - Institute - 

-- with copy 3 if head of household 

will not participate in program 

-- at time of " show for screen " of 
all children recorded on the form 

— at time of failure to establish an 
appointment after three contacts 
(including the initial interview) 

— after 90 days from date of contact 
(assumes head of household declines 
further participation) 

It is recommended that the Family Contact Card be produced in a 
pad form consisting of 10 contact sets (4 sheets per set) with a hard 
backing for writing convenience for the case-finding aide. 

Although performance measurement in the case-finding subsystem is 
primarily predicated upon population penetration (shows for screen 
proportional to the eligible population) the family contact card is 



4 



I 



210 



a means to measure contacts of eligibles, case-finding aides' per- 
formance achievement (proportion of "shows for screen" of those 
contacted), and related case-finding aides' activity variations 
(number of contacts per period of time). 

The "contact card" is also used to record a child's entry into 
the EPSDT data system. 
Screening Sheet 

1. Copies prepared: 4 

2. When prepared: At time child "shows" for screening 

3. Who prepares: Screening activity 

4. Distribution: Copy 1 - Screening Activity, record copy 

Copy 2 - Working/circulating copy (Screening 
activity) 

Copy 3 - Institute ( at time of completion_of 
first visit ) ~ ~" " 

Representing: "Show for screen" or 

"Completed screen", if so marked (one- 
shot screen) 

Copy 4 - Institute 

a. At time of screening completion (s.o 

marked ) or" 

b. Ninety days from date screening sheet 

originated, representing an incomplete 
screen 

It is assumed all screens, once initiated, can be completed in 90 

days. It is further assumed that, if not completed in 90 days, they 
are not completable because the family has moved or refuses to parti- 
cipate or cooperate, etc.) 



211 



As a double check, the computer will be programmed to print out 
monthly a listing, by name, of all screens not completed by the end 
of 90 days (copy 4 not received) for whom a screening initiation copy 
(copy 3) was received. This listing will be sent to the screening 
site for entry on the print-out opposite each name, the reason the 
screening was not completed, e.g., family moved, family declines 
further participation. This listing will be returned to the Institute 
within 21 days of mailing along with the applicable outstanding copies 
of the Screening Sheet (No. 4). 
5. Tests and Measurements 

The computer will be programmed to require that a normal or 
abnormal entry be made for each indication of a test required 
before it can recognize a valid screening completion. This is a 
check to assure that test results are received and recorded. In- 
structions in the narrative pertaining to this section indicate 
that if the State or local guidelines require a retest for all 
first abnormal results, a check (/) will be made on the appropriate 
line in the retest column— and that no entry will be made under 
results until the retest results are received . 

In this situation if a form is marked with a test required, 
and there is also a retest check (/) on the same line, it will be 
assumed that the first result was abnormal and that a retest result 



212 



is pending. 

If any line is marked with a test required and a (/) on the 
same line for a normal result, it is assumed that the test is 
complete. 

If any line is marked with a test required and a (/) on the 
same line under retest with a (/) also under the abnormal result, 
it is assumed that the first test was abnormal and that finding 
confirmed by the second test. 

If any line is marked with a test required and a (/) on the 
same line under retest with a (/) also under the normal result, 
it is assumed that the first test was abnormal but the second 
test (confirming test) was normal and the conclusion is the test 
sequence is normal and complete. 
Screening Completion 

The computer program will recognize a screening completion 
when the box so indicating is checked " Yes" and when the following 
additional conditions are met: 

a. A normal or abnormal entry has been made indicating a result 
for each test checked (/) as required. 

b. A child healthiness rating is indicated. 

c. The person's name and staff code (who completed the healthiness 
rating and the last two right hand columns) is entered in the 
appropriate boxes. 

Additionally, the Institute will reject as incomplete all 
screening copies received not having complete data on the upper 



4 



213 



section of the form and in Vital Signs and Measurements. 
Immunization Annex 

1. Copies prepared: 4 

2. When prepared: At time child shows for screening 

3. Who prepares: Screening activity 

4. Distribution: Copy 1 - Screening activity, record copy 

Copy 2 - Working/ circulation copy (Screening 
activity) 

Copy 3 - Institute (at time of completion of 
first visit) 

Copy 4 - Institute (at time immunizations achieve 
status of "complete for age") or 

120 days from date Irrenunization Annex 
originated , representing an incom- 
plete status of immunization. 

5. a. The "Routinely required for child this age" column represents 

the immunizations the child requires to be "complete for age". 

b. The "Has child had this immunization - including this visit" 
column represents the status of immunization of the child at 
the end of the initial visit for screening. 

c. The "Subsequent immunizations - Current series - Date required" 
column represents the immunizations required to achieve a 
status of "complete for age". By the schedules prescribed in 
the Annex, this is achievable in all instances in a four month 
period. 

d. The "Subsequent immunizations - Current series - Date received" 
column represents the dates immunizations prescribed in the 
"required" column are administered. When there is a date in 



4 



214 



this column matching all dates in the "required" column, the 
status of immunization will be "current for age". 

6. The Institute copy (No. 4) will be forwarded to the Institute, 
as is, 120 days following date of initiation. If there is not a 
date in the final (right) column matching all dates in the 

"Date required" column, this will represent an incomplete immuniza- 
tion. 

7. As a double check, the computer will be programmed to monthly 
print out a listing, by name, of all immunizations not completed 

by the end of 120 days (Copy 4 not received), for whom an immuniza- 
tion initiation copy was received (Copy 3). This listing will be 
sent to the screening site as a reminder of "outstanding-incomplete" 
immunizations and will request an entry on the print-out opposite 
each name citing the reason the immunizations were not completed, 
e.g., family moved, family declines further participation, etc. 
This listing will be returned to the Institute within 21 days of 
mailing along with the applicable copies of the outstanding 
Immunizations Annex (No. 4). 

8. Measurement of the change in status of immunizations in children 
prior to the initial visit for an EPSDT screen and four months 
later will be accomplished. 

Measurement will be made of the number of children not current 
for age in their immunizations at the time of show for screen and 
those of this group "current for age" four months later. 

"Not current for age" at the time just prior to the initial show 
for screen is defined as those children for whom an entry in 



r 



215 



the immunization form of a date in column 2 (Current Status - 
Has child had this immunization -- including this visit?) co- 
incides with the date on the form in the upper right corner 
or a date entry is recorded in column 3 (Date Required). 

"Current for Age" is defined as those children for whom a 
date is entered in column 2 or 4 matching all entries recorded 
in columns 1 or 3. 

A sample of 200 children who "showed for screen" in the 
period 120-210 days prior to the end date of a quarterly report 
period and who were "not current for age" in immunizations will 
be evaluated to determine the proportion that had been converted 
to "current for age" by the end date of the report period. 
Problem Referral and Case-monitoring Sheet 

1 . Copies prepared: 5 

2. When prepared: When (/) "Yes" is entered for any category 

final (right) column "Problem Sheet Originated" 
of the screening sheet. 

3. Who prepares: Primary screener; person whose last name was 

entered in item 13 of the screening sheet. 

4. Distribution: Copy 1 - Screening Activity 

Copy 2 - Case Monitor (Control copy) 

Copy 3 - Practitioner Case Monitor 

Copy 4 - Institute , at time of receipt by the 
case monitor from the screening 
activity 

Copy 5 - Institute 

a. At time of problem resolution (as 

checked) or 

b. 180 days from date problem sheet 

originated, representing an 
unresolved problem 



216 



It is assumed almost all problems, once identified, can be re- 
solved in one form or another in 180 days. It is further assumed 
that if not resolved within 180 days, they are not resolvable be- 
cause of such administrative reasons as the family no longer being 
Medicaid eligible, or moved, and such professional reasons as still 
being under care and/or referred for further care. 

As a double check, the computer will be programmed to print-out 
monthly a listing, by name, of all problems not resolved by the end 
of 180 days (Copy 5 not received) for whom a problem initiation copy 
(Copy 4) was received. This listing will be sent to the case- 
monitor for entry on the print-out opposite each name, the reason 
the problem was not resolved. This listing will be returned to the 
Institute within 21 days of mailing. Print-outs on these cases will 
be forwarded for explanation, if Copy 5 is not received, at bi- 
monthly intervals thereafter. 

Another control imposed will be to program the computer to 
furnish, monthly, a print-out by name of all screening sheets com- 
pleted in which a "problem sheet identified" was checked (/) "Yes" 
but for whom no problem sheet (Copy 4) was ever received. 

Multiple Referrals 

When the caseworker receives a referral sheet (Copy 3) from 
a practitioner which indicates a need for a child to be referred to 
another specialist, a new problem sheet will be originated. This 
problem sheet will contain, as a write-in, the same document 
control number as the original problem/ referral sheet, but with 



217 



the added suffixes as previously discussed. (If there is another 
overprint number on this form, it will be scratched out.) This 
sheet will then be processed in the same way as an original 
problem/referral sheet with the same number and distribution of 
copies. The six month control period for problem referral and 
resolution will still, however, relate to the date of the original 
problem referral sheet. 



218 



XII. AN EXAMPLE OF AN OVERALL RESEARCH FORMAT FOR MULTIPLE DEMONSTRATIONS 
(A model with four demonstration projects) 

The schematic irmiediately following is a format, as an example, for 
testing 60 designated operational variables involved in performance impact 
in the five subsystems of EPSDT (case finding, screening, diagnosis, treatment 
and case monitoring) as well as the three most significant age-group variables 
within the total age span of eligibility (0-21) in four demonstration projects. 

The 60 operational variables represent a consensus from conferences with 
state and local EPSDT program personnel and SRS national and regional personnel, 
of factors considered most appropriate and significant to test in EPSDT demon- 
stration models to determine their effectiveness, relative costs and probable 
program applicability. The three age variables (0-5, 6-18, 19-20) are intro- 
duced to identify the impact of the operational factors (and related costs) 
on the respective age groups. Each of these age groups presents differing 
problems (and generates differing costs) in achieving increased rates of 
performance in the respective EPSDT subsystems. Each age group represents 
a differing degree of "pay-off" potential for operational implementation. 

In an R&D plan comprising four EPSDT demonstration models they are 
presumed, in this format, to be divisible into at least 22 geographically, 
demographically and statistically isolatable experimental subsectors. Such 
division of a site by census tract, welfare or health districts, etc., is 
essential to appropriately test a large number of variables. Additionally, 
in this format, the three year time frame of an EPSDT demonstration is sub- 
divided into 16 time periods to afford broader testing potentiality within 
the limits of four sites/22 sectors. In essence, a maximum of 180 (60 opera- 
tional variables and three age variables) sub-experiments are contained within 
this overall R&D framework. 



219 



Almost without exception, and where appropriate, these sub-experiments 
are repeated, generally, in at least three - four sectors in two different 
demonstration sites. Presuming tight definitional control of terms, uniform 
standards of normal and abnormal, strict adherence to these standards and 
disciplined informational input for all four demonstrations, data from this 
design would be considered reasonably high in reliability for transfer of the 
results to other similar environm&hts. 



RESEARCt 



V A 



I i A B !L E 



1 . ESTABLISjJ DATA ,['ASE_ o(l ONGOJMG PROtsRAM 



UB^ 



SUBSYSTEM 



CASE FINDING 



Tlyer wilh check 



4. "Letter fyo m casjewor ke • 

STTeUer fFom director,] Dept 

g--- B„ -t„ 



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10._ felepho|ie callj from tasewoijker 

T 1 1. JHpnie_ V 1 !! it frcn case' rorker 



as ;f indi 



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je^UntentiVe payrient - -V£lfar4,fii4hts.._(^3 
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RtSEARCH rosm FOR ItSTlriG 60 OPERATIOMS AMD 3 ACE VflHlSBUS IM AH tPSDT OEHONSTHArlON PROGRAM (4 SITES/ZZ SECTORS) 





M 



221 



XIII - 



(AN EXAMPLE) 



RESEARCH FORMAT 
FOR 

THE CASE FINDING AND CASE MONITORING SUBSYSTEMS 
AS A COMPONENT OF 
. A new" DEMONSTRATION IN AN URBAN SETTING 



(A 36-MONTH PROJECTION) 



Health Services Research Institute 
The University of Texas Health Science Center 
San Antonio, Texas 



First Working Draft - Prepared February 17, 1975 



(Prepared under a Grant Awarded by the Social and Rehabilitation Service, DHEW) 



GENERAL 



CONTENTS 



Page 



SECTION I 
(THE CASE FINDING SUBSYSTEM) 



Subsystem Designation 3 

Subsystem Objectives 3 

Assumption 3 

The Total Experiment 3 

Research Objective 4 

Indicator of Subsystem Performance in Each of the Experimental Groups and 4 
in Total 

Formulae to Determine Penetration Rate and Average Cost 4 

Experimental Factors to be Tested 5 

Research Schema 7 

Area and Task Related Configuration 8 

Time and Task Related Configuration 3 

Constraints or Assumptions to Assure the Significance of the Findings q 

Full Time Employed Case Finding Aides 10 

Objective 10 

Configuration 11 

Prerequisites for case finding aides 12 

Pre-test training for case finding aides 12 

Case finding aides - work performance task goals 13 

Forecast 13 

Incentive Payment to Parent - Transportation Fee 15 

Objective 15 

Configuration 15 

Functions and prerequisites for sector program coordinators 17 

Pre-test training for sector case finding program coordinators 18 
Case finding sector program coordinators - Work performance task goals 18 

Forecast 19 

Incentive Payment to Community or Welfare Rights Organization for Case 

Finding 21 

Objective 21 

Configuration 21 
Functions and prerequisites for case finding sector program coordinators 25 
Pre-test training for the case finding sector program coordinators 25 
Case finding sector program coordinators-Work performance task goals 26 
Forecast 26 



Mass Media - Paid TV/Radio Combined, as Case Finding Technique 27 

Objective 27 

Configuration 27 

Functions and Prerequisites 29 

Pre-test training 29 

Work performance Task Goals 30 

Forecast 30 

SECTION II 
(THE CASE MONITORING SUBSYSTEM) 

Subsystem Designation 32 

Subsystem Objectives 32 

Assumptions 32 

The Total Experiment 32 

Research Objective 33 

Indicator of Subsystem Performance in Each of the Experimental Groups and 33 
in Total 

Formulae to Determine Case Completion Rates and Average Cost 33 

Experimental Factors to be Tested 34 

Research Schema 36 

Area and Task Related Configuration 36 

Time and task related configuration 36 

Constraints or assumptions to assure the significance of the findings 38 

Full Time Case Monitors 38 

Objective 38 

Configuration 38 

Prerequisite for case monitors 39 

Public health nurse 39 

Social worker 39 

Case monitoring aide 39 

Pre-test training for case monitors 40 

Case monitors - Work Performance Task Goals 40 

Forecast 41 

SECTION III 



First 12 Month Overall Cost Forecast 



43 



t 



f 



1 

GENERAL : This format assumes that there are only sufficient funds available 
to sponsor two new demonstrations at reduced activity levels. As a consequence, 
focus will be placed upon the case finding and case monitoring subsystems. 

It is assumed these demonstrations will take place in major urban complexes 
in which a high density of eligibles exists and that some major factors to be 
tested will be duplicated in both demonstrations to ascertain reliability of 
results and reasonable probability of their transferability with equal effect 
to other major urban complexes. 

Immediately following (Figure I) is a research design overview indicating 
the major factors to be tested in these two subsystems as well as research 
controls, assumptions, and measured variables. 

Sections I and II of this paper are the details of the research format 
and schema for these two subsystems, respectively, projected for 36 months 
and include forecasts (projection of results and costs) which have the primary 
purpose of providing a base for planning demonstration cost estimates. 

Processes, procedures, methods, definitions, systems flow, quality control, 
evaluation, etc., will be generally as prescribed in the Evaluation Handbook - 
EPSDT Demonstration Model, Health Services Research Institute, University of 
Texas Health Science Center at San Antonio. 



RESEARCH DESIGN OVERVIEW 
NEW DEMONSTRATION MINIMUM COST MODEL 
(RESEARCH FOCUS - CASE FINDING AND CASE MONITORING SUBSYSTEMS) 



RESEARCH CONSTRAINTS 



MAJOR FACTORS TO BE TESTED 



CASE FINDING SUBSYSTEM 

Control For: 

Test population variables 

Demonstration staff 
variables 



FULL TIME CASE FINDING AIDES 



Operational variables 



Assumed Random 

Aides : 
Age 

Education 

Sex (parental status) 

Language 

Background 

Abode 

Preparation course (40 Hrs.) 
Control Screening Apmt. Avail- 
Standardize: ability 



Environmental variables 
MEASURE VARIABLE OF: 




Provision of transportation 
Hours of work 
Clinic hours 

Extent of services provided 
All other operational act. 
to a feasible maximum 



Assumed standard 

Family Contacts' 
Shows for screen 
Penetration rate 
Average cost per show for 
screen 



TRANSPORTATION FEE TO 
PARENTS 



INCENTIVE PAYMENTS 



Assumed Random 



Sector 



Coord inatpr! Orgnztns. 
Experience | Personnel 

(work) 
Education 
Language 
Abode 



Comminity 



Assumed 
random 



— > Ditto 

Exclude provision of direct 
transportation ^ 

—» Ditto 



Comminity Organizations 
(Techniques uncontrolled, 
note & measure impact) 

Assumed standard 

Letter mailings 
Shows for screen 
Penetration rate 
Average cost per show 

for screen 
Telephone contacts 



IMCEMTIVE FEE TO COMMUNITY 
ORGANIZATION 



Assumed Random 



Sector 


Community 


Coordinators 


Orgnztns. 


Language 


Personnel 


Experience 




(work) 




Education 


Assumed 


Abode 


random 


■> Ditto 



Standardize provision of direct 
transportation 

—> Ditto 



Connuni ty Organi zations 
(Technioues uncontrolled, 
note & measure impact) 

Assumed standard 



MASS MEDIA 



Assumed Random 

All previous as applied to 
sector 2 (incentive pmt. to 
community Orgn. reinforces) & 
sectors 3 & 5 (full time case 
finding aides reinforce) 
Sectors 1,4 (Solely media 
impact) 



► Ditto 



Assumed standard 



Shows for screen (overall & by org) Shows for screen-by sector groups 



Penetration rate( 
Aver, cost per show for screen 



Penetration rate 
Groups 1 & 4 
2 

3 & 5 
6 

Aver, cost per show for screen 



CASE MONITORING SUBSYSTEM 



CATEGORIES OF PERSONNEL AS CASE MONITORS 

fUBLIC HEALTH NURSE ~ 



Control For: 

Test Population Variables 

Demonstration staff 
variables 



Operational variables 



Environmental variables 
MEASURE VARIABLE OF: 



Assumed random 

Case Monitors: 

Education 
Experience (work) 
Language 
Background 

Preparatory course (40 Hrs) 

Work methods uncontrolled (Note ft 

measure Impact) 
Standardize: Work tools (telephone, 
etc.) 

All other applicable 

Assumed standard 

Problems completed 
Cases completed 
Screens completed 
Rescreens completed 



SOCIAL WORKER" 



Assumed random 
Case Monitors: 

— ^ Ditto 

— > Ditto 

Assumed standard 
— > Ditto 



■CURT 



Assumed random 
Case Monitors: 



■> Ditto 



> Ditto 

Assumed standard 
> Ditto 



f 



r 



3 



SECTION I 



Subsystem : Case finding 

Subsystem Objective : Maximize the number of eligible children brought in for 
EPSDT screening ("show for screening") at the least possible cost. 

Assumptions : Altering resources and means committed to outreach (case finding) 
will vary the costs and the "show for screening" rate for the eligible 
population. 

The Total Experiment : A comparison of the rates of show and the cost per show 

between case finding personal visits (with planned variations), incentive 
programs, and mass media with the existing program as a control group. 
Tested hypothesis at a = .05: 

1. ^Ho: penetration rates will be equal for each technique. 
^Ha: penetration rates will be different for each technique. 

2. Ho: Dollars per child showing for screen will be equal. 

2 

Ha: Dollars per child showing for screen will be different. 

2 

Statistical tests: 



No. shown 
No. not shown 



Case Aides 


Transportation 
Fee 


Incentive 
to Orqnztns. 


Mass 
Media 









Xl3 


Xiit 


ni. 


X21 


X22 


X23 


X21+ 


n2. 


n.i 


n.2 


n.3 


n . 


N 



If x2 calculated >x^ 

3 df table 
the best rates. 



, then reject ^Ho and look further to discover 



If the null hypothesis is not accepted, t-test on proportions will 
be made to determin%.wheVe the differences in show rates exist. 




4 



Ialil£ _of Proportions 



Method of case finding 



2 



3 



4 



5 



Show for Screen 



n.i 






X 



15 



n.2 



Tested hypothesis at a = .05 




Additional tests will be made comparing all proportions with each 



other. 



Research Objective : Demonstrate for decision makers at all levels associated with EPSDT 
in major urban complexes the most effective and feasible means and their respec- 
tive costs to achieve high penetration rates into the eligible populations. 

Indicator of Subsystem Performance in Each of the Experimental Groups and in Total : 
Rate of "shows for screen" (penetration rate) per average cost per show. 

Formula to Determine Penetration Rate and Average Cost per Show : 

If Cohort System Employed 

# of "shows" # of "shows" of # of "shows" of 

RATE : of eligibles + now^ not eligible + newly^ eligibles = % (rate) of "shows" 

# currently eligible + # of "shows" of now not eligible for screening 

COSTS : Operating costs • • case finding subsystem = Average cost per "show for 

No. of show for screening during report period screening" at rate of 

(Total of numerator in the above rate formula) shows for screening. 

Mt end of report period (lost eligibility during report period) 
^Gained eligibility during report period 



If Cohort System Not Employed 



# of "shows" of eligibles 
RATE : # eligibles on last day of = % (rate) of "shows for screening 
report period 



M 



Operating costs" case finding subsystem = Average cost per "show for 

COSTS: No. of shows for screening during report period screening" at rate of 

shows for screening. 



Experimental Factors to be Tested : 

1. Full time case finding aides (home visits) 

2. Incentive payment (to parent - transportation fee $8.00 per show) 
(with varying means of informing parents) 

3. Incentive payment (to voluntary community organization or 
community welfare rights organization; $7.50 per show). 

4. Mass media - paid TV and radio spots and features. 

The four factors selected to be tested are considered to be those 
with the greatest impact potential on the penetration rate of the 28 cited 
in the "Research Format for Testing 60 Operations and Three Age Variables in 
an EPSDT Demonstration Program (four sites - 22 sectors)". This pre- 
selection has been made because of the now likely possibility that, at the 
most, no more than two new demonstrations will be approved for this coming 
fiscal year (FY 76). To even reasonably assure transferability of the 
results of these demonstrations, it is necessary to reduce the number of 
variables to be tested. 

The consensus of the literature on outreach and preliminary evaluation 
of the results of the four ongoing EPSDT demonstrations indicates that home 
visits or other forms of personal contact with the parents are the minimal 
means of those means normally used for outreach to achieve appropriate 
levels of penetration results. This finding excludes the testing of such 
means as fliers, letters, telephone contacts, etc., as a primary means of 
outreach. In this research schema, several forms of personal contact are 
to be evaluated, i.e., full time project-employed case finding aides, and 
aides working on an incentive basis ($ per show) as agents of community 
organizations such as welfare rights or volunteers under contract with the 
project for case finding (outreach). 



6 



Also introduced for separate evaluation is a means of outreach upon 
which little information exists but which could potentially be highly effec- 
tive. This is the payment of a transportation fee to the parent for each 
child brought in for "stiow". This is an option that is controversial be- 
cause of the "apparent" payment of a fee to a client to receive a publicly 
provided service. Nevertheless, should it prove to be as effective (or nearly 
so) in penetrating the eligible population as case aides at a lesser cost, it 
would certainly be worthy of consideration for future program adoption. The 
limitation on this means may derive from the possibility of fraudulent abuse 
such as "fee" paying for ineligible children or repeated payment at various 
locations and times for the same children. Tight control of eligibility and, 
perhaps, restriction of fee payment to specific sites for specific sectors 
or sub-sectors. 

The other factors to be tested, which have great potential for case find- 
ing, which are innovative, and upon which there is not a great amount of data 
for this purpose, is the use of mass media. As previously indicated (Major 
Experimental Factors to be Tested}, four versions of mass med^'a were contem- 
plated, but these were in the context of four separate demonstration sites. 
By its nature, mass media literally precludes the testing of more than one 
version in a given demonstration within a normal three year period, if cumu- 
lative effects of more than one means are to be excluded (controlled) For 
example, if the use of radio spots was being evaluation in one phase and TV 
in a sequential phase, there would be no way of isolating the impact of TV 
itself, since it must be presumed that a significant part of the eligible 
population would have been exposed to both. In this demonstration, the mass 



media employed will be the combination option of radio and TV. 
Research Schema : The effectiveness (penetration of eligible population) and 

cost of the major factors to be tested will be compared with each other to 
determine which has the highest penetration rate at the lowest cost. 

Area and Task Related Configuration : The demonstration area is assumed 
to be divisible into at least six sectors which are statistically isolatable 
and geographically identifiable. Such sectors will consist of specific 
census tracts, blocks, etc., for which the demonstration governmental 
jurisdiction has the capability of providing associated lists of Medicaid 
eligibles. It is assumed that there are approximately 2500 Medicaid eligible 
families and 5000 eligible children in each sector. It is further assumed 
that where necessary each sector is divisible into two, three or four 
equal sub-sectors as required and that in these smaller configurations 
specific lists of eligibles (families and children) can be provided against 
which penetration results may be measured. 

Of the six sectors, at one time, three will be utilized to demonstrate 
the case-finding aide performance, two to demonstrate incentive payment to 
parents, and one will be utilized as a control sector to carry on the 
"before demonstration" activity to ascertain the relationship of accomplishment 
of the various testable factors to a base over time. 

Diagrammatically, this configuration would appear as follows during 
months 5-12 of the demonstration: 



r 



# I) 



8 



DEMONSTRATION AREA 



SECTORS 
-3 4 



6 

Control 



Full Time 



'Case finding- Incentive | Pre-Demo Cs.i 



5,000 
ChiTdren 


5,005 
Children 


5,000 
ChiTdren 


5,000 
CliiTdren 


5.000 
Children 


5.000 
Children 


166^ 

H 
1566 

Ci 
1566 


Ap 
1666 

Bo 
1666 

C2 
1666 


1666 

B3 
1666 

C3 
1666 









TIME FRAME 
Phase II- 
Demo. Mo. 
5-12 

(8 Month 

Test 

Period) 



Time and Task Related Configuration : The overall schema for testing 
of the four factors selected (with variations) throughout the duration of 
the demonstration (36 months) is portrayed in the following schematic. 

(See next page) 

Constraints or other Assumptions to Assure the Significance of the 
Findings : 

Standardization of operating procedure: Operating procedures in the 
gross sense must be standard for all sectors involved in this demonstration 
and most specifically in those sectors testing similar variations, i.e., 
full time case finding aides, incentive payment to parents, etc. The 
overall requirement for standardization becomes apparent when it is recog- 
nized that some of these test variations are inserted into other sectors at 
a later time frame. If the results between these sectors are to be com- 
parative, the sectors must similarly operate. The following are considered 
to be primary because of the significance they have been found to exert on 
"show" rates in other demonstrations or operational activities: 

- Screening appointment (either public or private sector) made, or allotted 



CASE FINDING - RESEARCH DEMONSTRATION SCHEMA 
SECTORS 



,lme 
(Months) 



1 
2 
3 
4 



7 
8 

9 

10 

n 

12 
13 

14 
15 
16 
17 
18 
19 

20 
21 
22 
23 
24 
25 
26 
27 
28 
29 

30 
31 
32 
33 
34 
35 
36 



1 



PHASE I 



Data Collection 



PHASE II 



Full Time 



Case Finding A 



Incentive Pay-Community Orgnztn. 

($^ per show for screen) 

(1 Prgm. Coordn.) (1 Prgm. Coordn) 



Mass 



Med 



i a 



Pre-Dembnstration Ongoing 



des - 



TV a 



Incentive-Trans. Fpp. to Parent 

($ Show for Screen) 

1st Letter notice to parents 
(1 Prgm. Coordn)] (1 Prog. Coordn) 

Incentive-Trans Fee to Parent 
2nd Letter notice to parents 

Incentive-Trans. .Fee to Parent 



Incentive-Trans. Fee to Parent 
Volunteer Orgn. -Publicize Program 
(1 Pr^. Coordn) (1 Prog. Coordn) 



Incentive-Trans. Fee to Parent 
Volunteer Orgn. -Publicize Program 
Prgm. Coordn. Tele. Contact w/Parent 



Activity 



Control - 

Cont. Pre-Demo. 



II 11 



II 11 II II 



Full Time Case Finding Aides 



nd Radio Spot 

H 



Mass media releases will stipulate direct contact with screening facility - 1 program coordinator per 
screening facility. 



10 



to case finding aides or community organizations for assignment to contacts 
must not extend beyond five days of the contact or expression of interest. 

- transportation provided by the project must be uniform in all sectors 
except that it should not be provided at all in these sectors testing the 
"transportation fee" to parents variable. 

- hours of work, screening and clinic hours need to be uniform in all 
sectors (unless this becomes a measured variable at a later date). 

- extent of services provided by screening activities must be uniform 
in all sectors. 

Assumptions - client, locational and staff variables: It is assumed 
that client and locational variables that may be caused by demographic, 
social or environmental characteristics, e.g., availability of transporta- 
tion (public or private), past health experience, health knowledge, per- 
ceived value of specific services, etc., are essentually the same in all 
sectors of the demonstration. In the same context, it must be assumed in 
the mass media phase that client exposure to the media campaign will be 
uniform in all sectors. 

It is also assumed that variations in staff attitudes and other staff 
characteristics not being tested are random and therefore, will not produce 
systematic bias in the result 

The following describes the schema for establishing each of the desig- 
nated experimental groups together with the estimated impact on the total 
project. 

Full Time Project-employed case finding aides 

Ohier.tivP! Establish the penetration rate that can be achieved by full 



( 







n 



time case finding aides of specified characteristics, under specified 
conditions. 

As an ancillary objective, determine the probable output potential of 
such aides under such conditions as expressed in workload terms, such as 
contacts per prescribed period, and the percentage of shows for screening 
(of those contacted) and the penetration rate per prescribed period at 
average "costs per show". 

Configuration : Those sectors that are to be utilized for demonstrating 
the factor of full time case finding aides will consist of specific census 
tracts, blocks, etc., with corresponding lists of Medicaid eligible families 
and children. It is assumed that there are approximately 5,000 Medicaid 
(EPSDT) eligible children in each sector. This test will divide the eli- 
gibles in each sector into three approximately equal increments, clustered 
by location within the sector (subsectors) . Two case finding aides and a 
case finding aide/supervisor will be employed per sector. This configuration 
will provide each case finding aide a basic list of approximately 1,660 
eligible children against which individual case finding aides and sector 
penetration results will be measured. 

The primary function of case finding aides is to contact parents of 
eligible children not previously screened in the home and persuade the 
parent to bring the child for an EPSDT screen. Standard Department of Labor 
(DOL) nomenclature and job description of job tasks will be utilized to the 
maximum in establishing case finding aide tasks, job classification and wage 
scales. The DOL Dictionary of Occupational Titles and other similar aids 
will be utilized to the maximum. This procedure is imperative if compara- 
bility of data between demonstrations is to be validly established and 
transferability of data reasonably assured. 



( I 



12 



Prerequisite for Case finding Aide : Based upon the current literature 
on outreach aides and the results of the four ongoing EPSDT demonstrations » 
the following prerequisites represent those features of aides most likely 
to assure higher rates of individual performance in a major urban area 
where the target population is clustered in a "ghetto" or slum and includes 
other constraints to assure that personnel variables do not significantly 
affect the results in the overall. 

. indigenous to demonstration area (at least the sector, but not 

necessarily the subsector) 
. minimum 8th grade education (preferably not to exceed a 12th gr^ade 
education - this maximum is added to control for education in individual 
performance in the research design) 
. bi -lingual (in the language of the demonstration sector - if it is 

bi-lingual ) 
.22-32 years of age 
. mother 

. no previous experience as an outreach worker 

Pre-test Training for Case Finding Aides : All case finding aides 
will be instructed in a job preparation course of approximately 40 hours 
covering such subjects as EPSDT program purpose, advantages and goals, 
research objectives, job quotas, outreach methods and techniques, etc. A 
training program for case workers is in the final stage of development 
by the School of Social Work, University of Texas at Austin under contract 
with SRS Region VI. This material will be utilized to establish a standard 
case aide, 40 hour training program for use in all demonstrations. 




i 



13 



Case Finding Aide - Work Performance Task Goals : 

Family personal home contacts per week 50 
(Assume an average of two eligible children per contact) 

Rate of show for screening by end of first week 35% 

Rate of show for screening by end of second week 45% 

Rate of show for screening by end of third week 50% 



Forecast : * (for computation of costs, exemplification of methodology . 

and estimation of variable impact) Demonstration 
Subsect or Sector Total 

(1 case aide per 
subsector) . (3) 
8 family contacts 
per day per aide. 
(Assume 2 eligible 
children per contact 
= 16 children con- 
tacts per day or 
(16x5) 80 per week 

per aide ^80x3-240 per week per sector. (Assume 

50% shows from contacts )**(8 month 
test period - 8x30 days = 240 days * 
7 = 34 complete weeks ). 240 x .50 = 
120 shows per week (120 x 34) = 4080 
shows for screening in 8 months (34 
weeks) . 

(Assume 1/3 of 5.000 eligibles 
turnover (gains or losses) during 8 
month period and that, therefore, 
1/3 of the 4,080 shows, or 1,359 are 

not part of the eligible population 
at the end of the report period. 
Remaining show for screening eligi- 
bles = 2,721. Further assume that 
45% of the new eligibles (1,359 X. 45) 
or 612, are contacted and show for 
screening; therefore, total shows 
for screens of eligible at the end of 
the 8 month period is 

(612 + 2,721 = 3,333) > 3,333 x 3 = 9,999, 

Total eligible 
population is 
15,000. The 
number of "shows 
for screens" of 



I 



14 



(Continued from previous page) 
Subsector -Sector 



Demonstration 
Total 

eligibles at the 
end of the 
8 months is 9,999. 
9,999 T 15,000 = 
67% rate of shows 
for screen. 



Costs 

Direct 

1 case aide at $6500 
per annum = .66 x 
6500 » 4,290 



■> 4,290 X 3 = 12,870 



(orig. eligibles show 4,080 
"(new eligibles show 612 



■> $12,870 X 3 = $38,610 
(14,076 shows for 
screening) 



4,692 X 3 



Indirect 



Total 



38,610 T 14,076 = 
2.74 - Direct 
cost per show 

2.74 X .26*** = .71 

2.74 + .71 = 3.45 



RECAP: 67% penetration rate achieved (rate of shows for screening at 

$3.45 average cost per show for screen. 

*Assumes a level of performance somewhat less than the " goals " for work 
performance tasks specified on page 

**End of eight month test period is also end of demonstration month 12. (4 
months Phase 1+8 months Phase II) 



***Indirect costs represent the case 
total indirect costs of the total 
rent, utilities, supplies, admini 
depreciation. Using Contra Costa 
demonstration planning projection 
tion, it was found that indirect 
of the direct costs. Therefore, 
show for screening (2.74 x .26 =) 



finding subsystem's assigned share of the 
operating costs. These indirect costs include 
strative personnel, telephone equipment 
cost data, which should be close to any new 
because of the planned similarity of configura- 
costs for the case finding subsystem are 26% 
in this projection, 26% of the direct costs per 
is $0.71. 



15 



Incentive Payment to Parent - Transportation Fee 

Objective : Establish the penetration rate that can be achieved by paying 
a "fee" (transportation fee - $8.00 per child that shows for screening) 
weekly to parents for eligible children brought in for screening. 

Configuration : Two of the six sectors will initially be utilized for 
testing this experimental variation. It is assumed that these two sectors 
can also be provided lists of Medicaid eligible families and that there are 
approximately 2,500 Medicaid eligible families (5,000 children) in each 
sector. 

One case finding program coordinator will be employed per sector. 

The same techniques will be utilized in each sector to inform the 
eligible families of the program. 

In the first three months of Phase II, two mailings will be made (one at 
the beginning of the first month and one, with a different notice, at the 
beginning of the sixth week) advising eligible families of the program, the 
fee, and the point of contact (the program coo»«Jinator) to make a screening 
appointment.* Penetration rates and costs will be determined for this techni- 
que of advising eligibles and assessing their response to a "transportation 
fee". 

During this first three months, the case finding sector program 
coordinator or coordinators (jointly) will also establish contact with 
community organizations (church groups, unions, welfare rights organizations, 
etc.), to arrange for their voluntary and cooperative support in an informa- 
tive outreach campaign to cover the following five months. 

In this subsequent five months, these organizations will conduct a 

*Both mailings will be phased over a period of six weeks, with approxi- 
mately 1/6 (of 2,500) of the total notices being mailed each week (approximately 
420 per week). v kk j 



c 



( 



16 



general informational program concerning EPSDT and the transportation fee 
through all means by which they normally communicate with the "clients" 
and the public, e.g., bulletins, organizational "newspapers", meetings, 
posters, etc. The means used and the time frames in which they are used 
must be carefully monitored and reported by the sector program coordinator. 
Penetration rates and costs will be determined for this technique of advising 
eligibles and assessing their response to a "transportation fee". 

In the following six month period (demonstration months 13 - 18; refer 
to Case Finding - Research Demonstration Schema - Time and Task Related 
Configuration), the above procedure will be continued but will be reinforced 
by the sector program coordinators making direct telephone contact with 
lists of eligibles, covering a specific sub-area of their respective 
sectors. This sub-area would be similar to one of the three sub-areas indi- 
cated in the earlier schematic (Area and Task Related Configuration) for 
Sectors 1, 2, and 3 (for demonstration months 5 - 12). The rates and costs 
of this means will be compared with those of the community organization results 
alone. Diagrammatical ly, this configuration would appear as follows: 

4 SECTORS 5 



Demonstration 
months 5-7 



Demonstration 
months 8-12 



1 Sector Prog. Coordinator 


1 Sector Prog. Coordinator 


2,500 families 
5,000 children 


2,500 families 
5,000 children 


1st letter notice to fam. 
2nd letter notice to fam. 


1st letter notice to families 
2nd letter notice to families 




1 Sector Prog. Coordinator 


1 Sector Prog. Coordinator 


2,500 families 
5,000 children 


2,500 families 
5,000 children 


Voluntary organizations 
promote program 


Voluntary organizations 
promote program 



( 



( 



■ 



17 



4 SECTORS 5 





1 Sector Prog. Coordinator 


1 Sector Prog. Coordinator 




2,500 families 


2,500 families 


Demonstra- 


5,000 children 


5,000 children 


tion 


Voluntary Organization 


Voluntary Organization 


months 13-18 


jDromote £roc[ram 


promote program 




Telephone contact 


Telephone contact 




reinforce 


reinforce 



A^ & c (833 families; 1666 children - program coordinator reinforces 
voluntary organization efforts by telephone contact with a 
specific list of eligibles within the sectors. 



In demonstration months 19 - 30 the use of community organizations in 
a program promotion role will be discontinued and full time case finding 
aides will be utilized in the ensuing 12 months (demonstration months 
19 - 30) to ascertain the relative penetration impact on a "back to back" 
basis of full time case finding aides in contrast to the transportation 
fee method. 

(The case finding aides utilized in sectors 1 and 2 will be transferred 
do these sectors (4 and 5). Full time case finding aides will be discon- 
tinued in sectors 1 and 2 at that time. All controls and conditions speci- 
fied in the discussion of the utilization of case finding aides will apply.) 

Functions and Prerequisites for Sector Program Coordinators : The 
primary function of sector program coordinators is to manage the EPSDT case 
finding efforts in their respective sectors. This includes execution of the 
two letter notices, , (demonstration months 5 - 7); contacting, negotiating 
with, arranging for, and maintaining control of the efforts of community 
organizations in the promotion of the EPSDT program (demonstration months 
8 - 18); contacting by telephone eligible families in a specific sub-area 
of their sector to reinforce the efforts of the community organization in 
advising parents concerning the program, the transportation fee, and attempt 
to persuade them to bring eligible children to screening. 



18 



Other functions will include working with the screening facility to 
coordinate the outreach - casefinding efforts with the screening activities » 
coordinate screening appointments, pay the transportation fee, etc. 

Sector program coordinators will be social work qual ified, both by 
education and experience. Standard DOL nomenclature of job description 
and job tasks (including the DOT) will be utilized to the maximum in 
establishing job tasks and classification and wage scales. These procedures 
are imperative if comparability of data between demonstrations is to be 
validly established and transferability of data reasonably assured. 

Prerequisites for Sector Program Coordinators : 

- indigeneous to demonstration area - preferably sectors 4 and 5 

- minimum of bachelor's degree; maximum master's - social science major 
- experience: minimum two years (maximum 5) experience in the social 

service fields in the demonstration city 

- bi-lingual (in the language of the demonstration sector, if it is 
bi-lingual ) 

Pre-test Training for Sector Program Coordinators : 

Attendance at the 40 hour job preparation course for case finding 

aides (see pre-test training for case finding aides). 

Sector Program Coordinators : Work Performance Task Goals 

Mail 2500 (1st mailing) letters by Mail 2500 letters 

end of the 2nd week of demonstration month 6 * 

Mail 2500 (2d mailing) letters by Mail 2500 letters 

end of the 4th week of demonstration month 7.** 

Establishing working relationship with Working contact 

all community organizations with significant with 10 community 

influence in the respective sectors (or organizations 
sectors jointly) by end of 1st week of 
demonstration month 7 

♦Initiate the mailing of 1/6 of the total letters by the end of the 1st 
week of demo month 5, and 1/6 each week for the following five weeks. 



In a manner similar to the first mailing. 



( 'I 



f I 



19 



Coordinate screening appointment for 40 appointments 

parents applying under transportation fee per day 
incentive. 

Pay transportation fee to parents per 40 transportation 

child that "shows for screen". fees paid per day 

Contact eligible families by telephone 10 per day 
(demonstration months 13-18). 



Forecast : (for computation of costs, exemplification of methodology and 
estimation of variable impact) 

Demonstration 
Sector Total 



Subsector 



A4 (& A5 ) 

Program Coordinator 
contact 10 families 
per day in a single 
subsector (833 families, 
1666 children) by 
telephone. Assume 
3 of 10 contacts show 
for screen. Assume 
sector shows for screen 
are equally distributed 
per subsector - there- 
fore this sector would 
have been producing 16 
per day in demonstration 
months 5-7 and 9 per day 
in demonstration months 
8012 and 12 per day in 
demonstration months 13-18. 



Demonstration Months 5-7 (3 months) 
Average 25 appointments per day 

(shows for screen) 
= (25x5) 125 shows for screen per week 
3 months demonstration period (12 weeks) 
= (125x12) 1500 shows for screen 

Demonstration Months 8-12 (5 months) 
Average 35 appointments per day 
(shows for screen) 
= (35x5) 175 shows for screen per week 
5 month demonstration period (21.5 weeks) 
= (21.5x175) 3762 shows for screen 

Demonstration Months 13-18 (6 months) 
Average 38 appointments per day 
(shows for screen) 

38 

35 from efforts of community organizations 
3 from efforts of program coordinator 

telephone calls (in Sector A^) 
38x5 = 190 shows for screen per week 

6 month demonstration period (26 weeks) 
26x190 = 4940 shows for screen. 




o 



20 



Total shows for screen 
Demo Months 5-7 
(6x5x12) = 360 

Demo Months 8-12 
(9x5x21.5) = 967 

Demo Months 13-18 
(12x5x26) = r560 



End of 8 months test period 
br 12 month Demo period) results 
(assume 1/3 of 5000 eligibles turnover 
(gains or losses) during 8 month 
period and that therefore 1/3 of the 
5262 shows (1500 + 3762), or 1752 are 
not part of the eligible population at 
the end of the report period. Remain- 
ing show for screen eligibles (5262 - 
1752) = 3510. Further assume that 
45% of the new eligibles (1752x.45) 
or 788, are contacted and show for 
screening; therefore, total shows for 
screens of eligibles at the end of 
the 8 month period is 

(3510 + 788 = 4298) > 4298 x 2 = 8596 

Total eligible 
population is 10,000. 



The number 
for screen 
at the end 
test month 
month) is 



of "shows 
of eligibles 
of the 8th 
(or 12 Demo 
8596. 



8596 T 10,000 = 86% 
of shows for screen, 



rate 



Costs 



Direct 




1 Sector Program Coordinator 

at $12,000 per annum (8/12 of a year) 

(.66 X 12,000) = $7920 

1/3 Clerk Typist Costs at $6000 

per annum = (6000x.66) x .33 = $1360 

$8.00 transportation fee for show 
for screening 

5262 shows (original eligibles) 
788 shows (new eligibles) 

6050 shows 



x2 = 12,100 shows 



6050 x 8.00 = 48,400 



( 



21 



Total Direct Costs 7,920 



1.306 
48,400 



57,626 X 2 



= $115,252 
(115,252 * 12,100 
=$9.52 — Direct 
Cost per show) 



Indirect — ' 



$9.52 X .26 = 2.48 



Total 



$9.52 + $2.48 = $12.00 



Recap : 86% penetration rate achieved 

(rate of shows for screening) at $12.00 
Average Cost for show for screen. 



1/ Indirect costs represent the case finding subsystems assigned share 
of the total indirect costs of the total operating costs. These 
indirect costs include rent, utilities, supplies, administrative 
personnel, telephones, equipment depreciation. Using Contra Costa 
cost data, which should be close to any new demonstration planning 
projection because of the planned similarity of overall organizational 
configuration, it was found that indirect costs for the case finding 
sub-system are 26% of the direct costs. Therefore, in this projection, 
26% of the direct costs per show for screening (9.52 x ,26 = 2.48. 

Incentive Payment to Community Organizations (Incentive fee for each 
eligible "show for screen") 

Objective : Establish the penetration rate that can be achieved by 
paying an incentive fee ($7.50) to designated community organizations for 
each eligible child it sponsors for EPSDT that "shows for screen." 

Configuration : Two of the six sectors will be utilized in demonstra- 
tion months 19-30 (12 months) for testing this experimental variation. 
It has already been assumed that the Medicaid eligible population is 
identifiable by sector or sub-sector for penetration measurement and that 
there are approximately 2500 Medicaid eligible families (5000 children) 
in each sector. 

One case finding program coordinator will be employed per sector. 
(These may be the two coordinators released from Sectors 4 & 5 at the 
conclusion of the^ Incentive Transportation Fee to Parent variation [see 
Case Finding - Research Demonstration, Schema]). 



( 



( 



22 



In one sector church groups, social /fraternal groups., etc. will be 
contacted and contracted with to solicit and sponsor program eligible 
children for screening at the rate of $7.50 per child that shows for screen. 
If it is not possible to provide those organizations specific target lists 
of eligible families^or reasons of confidentiality), they will need to 
approach the problem in a general context -- general rather than specific 
solicitation (whichever is utilized needs to be identified for the evaluator). 

In the other sector welfare rights organizations that have strong 
identification with the target population (e.g., Mexican-American Unity 
Council, NAACP, CORE, MAYO, etc.) will be contacted and contracted with 
(as interested and appropriate) to solicit and sponsor program eligible 
children for screening at the rate of $7.50 per child that shows for screen. 
General or specific solicitation will depend on the availability of eligibility 
1 ists. 

If eligibility lists are utilizable both sectors may be subdivided 
into smaller areas with various organizations contracting to target specific 
areas and related lists of eligibles. If eligibility lists are not 
utilizable small area assignments may be made for general solicitation or 
organizations may compete with each other over the total sector in a general 
solicitation (whichever is utilized needs to be identified for the evaluator). 

It is preferable in this variable to assess the effectiveness in 
program progress of the community organizations and welfare rights by 
sector, however, should it be deemed more appropriate to go one way or 
the other in both sectors -- the excluded variable will be tested in 
another demonstration. 

Contracts with selected organizations must provide for a specific 



23 



means of identifying a child that shows for screen with its sponsoring 
organization; must assure controls to preclude duplicate payments, and must 
provide for the periodicity and manner by which the participating organiza- 
tions are to be reimbursed. 

Means used by respective organizations for solicitation are uncon- 
strained other than that the sector case-finding program coordinator and 
the project director must have prior approval authority. Means used and 
the time frames in which they are used by participating organizations must 
be carefully monitored and reported by the case-finding sector program 
coordinator. Programmatically these configuration options would appear 
as follows: 

(See following page) 



24 



OPTION 1 



OPTION 2 



OPTION 3 



OPTION 4 



SECTORS 
(Demonstration Months 19-30) 

1 



~1 Sector Prog. Coordinator 


1 Sector Prog. Coordinator 


2,500 families 
5,000 children 


2,500 families 
5,000 children 


Community organizations 
(General solicitation 
throughout sector) 


Welfare Rights Orgnztns. 
(General solicitation 
throughout sector) 


Community organizations 


Welfare rights Orgnztns. 


Orgn. A ] Orgn. B 
General soli|citation by 
sub-^reas 

Orgn. C | Orgn. D 
1 


Organization A^ 
General solicitation by 
sub-areas 

Organization B2 


Community Organizations 


Welfare rights Orgnztns. 


Orgn. A -Specific solicita- 
tion in specific areas 
Or^n. B 
Orgn. C 


Orgn. Ag - Specific solici- 
tation in specific areas 
Orgn. B2 


Welfare Rights Organization 




OPTION 5 



Community Organizations 




25 



Functions and Prerequisites for Case Finding Sector Program Coordinators 

The primary function of case finding sector program coordinators is to 
manage the EPSDT case finding efforts in their respective sectors. This 
includes contacting, negotiating with, and arranging for contractual 
relationships with community and welfare rights organizations to promote 
the EPSDT program and solicit and sponsor eligible children for screening. 

Other functions will include working with the screening facility to 
coordinate the outreach-case finding efforts with the screening activities, 
coordinate screening appointments, pay the incentive fee, etc. 

Case finding sector program coordinators will be social work qualified 
both by education and experience. Standard DOL nomenclature (including 
the DOT) of job descriptions and job tasks will be utilized to the maxi- 
mum in establishing job tasks and classification and wage scales. These 
procedures are imperative if comparability of data between demonstrations 
is to be validly established and transferability of data reasonably assured. 
Prerequisites for Case Finding Sector Program Coordinators 

- indigenous to demonstration area 

- minimum bachelor's degree; maximum master's - social science major 

- experience - minimum two years (maximum five) experience in the social 
service fields in the demonstration city. 

- bi-lingual (in the language of the demonstration sector, if it is 
bi-lingual ) 

Pre-test Training for Sector Program Coordinators 

Attendance at the 40 hour job preparation course for case finding 
aides (see Pre-test Training for Case Finding Aides). 



( 



( 



26 



Case Finding Sector Program Coordinators - Work Performance/Task Goals 



Establishing working relationships with all community 
and welfare rights organizations with significant influence 
in the respective sector (or sectors jointly) by end of the 
2nd week of demonstration month 19. 

Coordinate screening appointments for parents applying 
under this plan. 



Pay incentive fee by monthly collection voucher to 
participating organizations. 



Making contact 
with 10 
community 
welfare rights 
organizations. 

50 appointments 
per day 

10 vouchers 
processed 
per month 



Forecast : (for computation of costs, exemplification of methodology, and 
estimation of variable impact) 

(The forecast based on option 1 - conmiunity welfare rights organizations 
in general solicitation throughout the total sector) 

Demonstration 

Subsecto r Sector Total 

Demonstration Months 19-30 (12 months) 
Average 30 shows for screen per day (from sponsored 
organizations) = 30 x 5 days = 150 shows for screen 
= 150 X 52 (weeks per year) = 7,800 shows, or for 
8 months (34.5 weeks) = 150 x 34.5 weeks = 5,175 
(8 month period selected findings for pur- 
comparison with other methods which were 

End of 8 months of 



shows, 
poses of 

based on 8 month estimates). 



test period (this variable) (or 26th month demon- 
stration period). Assume 1/3 of 5,000 eligibles 
turnover (gains or losses) during 8 month period and 
that, therefore, 1/3 of the 5,175 shows (5175 x .333) 
or 1,723 are not part of the eligible population at 
the end of the report period. Remaining show for 
screen eligibles (5,175 - 1,723) = 3,452. Further 
assume that 45^ of the newly eligibles (1723 x .45) 
or 775 are contacted and show for screening; therefore, 
total shows for screens of eligibles at the end of the 
8 month period is 3,452 + 775 = 4,227 > 



4,227 x 2 = 8,454 
Total eligible 
population is 
10,000; number of 
shows for screen 
of eligibles at 
end of 8th month 
of test period is 
8,454 T 10,000 = 
SS% rate of shows 
for screen. 



( 



27 



Costs 
Direct 

1 Sector Program Coordinator at $12,000 per annum 
(8/12 of year = .66)(.66 x 12,000) = $7,920. 1/3 
clerk typist at $6,000 per annum = (6,000 x .66) 
= $1,360 

$7.50 incentive payment ot community organizations 

for show for screening 

5,175 shows (original eligibles) 

775 shows (new eligibles) 
5,950 shows X 2 = 11 ,900 

5,950 X 7.50 = 44,625. 

Total Direct costs: 7,920 

1 ,360 
44,625 

53,905 X 2 =$107,810 t 

11 ,900 = 9.06 
direct cost per 
show 

9.06 X .26 = 
2.36 



Indirect"^ 



Total 9.06 X 2.36 = 

11.42 

RECAP: 85% penetration rate achieved (rate of shows for 

screening) at $11.42 average cost pyshow for screen . 

^Indirect costs represents the case finding subsystem's assigned share of the 
total indirect costs of the total operating costs. These indirect costs 
include rent, utilities, supplies, administrative personnel, telephone, equip- 
ment depreciation. Using Contra Costa cost data, which should be close to 
any new demonstration planning projection because of the planned similarity 
of configuration, it was found that indirect costs for the case finding 
subsystem are 26% of the direct costs. 

Mass Media - Paid TV/Radio as Case Finding Techniques 

Objective : Establish the penetration rate that can be achieved by use 
of mass media (radio and TV spots and features) in itself and as reinforced 
by (or reinforcing to) such other case finding activities as full time aides 
and community organizations working on a fee incentive basis. 

Configuration : All six sectors will be utilized in demonstration months 
31 - 36 to test this variation and its component modifications. Diagrammati- 
cally, the configuration of sectors and means would appear as follows: 



( 



28 



SECTORS 



Demonstration 
Months 31 - 36 



4 



MASS MEDIA -.RADIO & TV SPOTS 




Incentive 
payment to 
community 
organiztn. 
($7.50 per 
show for 
screen) 


Full time 
case finding 
aides 




Full time 
case finding 
aides 


Control 
(The origi- 
nal ongoing 
program) 



The sector eligible populations continue to consist of 2,500 families and 
5,000 children. The assumption continues to be made that these program eli- 
gibles are identifiable by sector and sub-sector for penetration measurement. 

The demonstration project director will contract with local advertising- 
marketing-public relations agencies with multi -media capability to develop 
a series of 10 one-minute TV spots and 10 one-minute radio spots to be 
utilized in the mass media campaign. These TV and radio "spots" will focus 
on local area and population and the advantages of the EPSDT program for the 
child and family, the services provided, the client reaction derived, etc. 
A theme of preventive health care, as distinct from acute episodic care, will 
be woven throughout all mass media releases. It is estimated that the 10 
radio spots will cost approximately $6,000 ($600 each) and the 10 TV spots 
approximately $20,000 ($2,000 each). These spots are cost estimated at a 
high quality level. Wherever feasible, companies with high identification 
with the target population should be utilized. If the target population is 
multi-lingual and there are appropriate foreign language transmitting sta- 
tions, appropriate foreign language duplicates of the respective TV and 
radio tapes should be made. 

It is assumed that no air time charges are involved. It is anticipated 



( 




( 



( 



29 



that air time, both for TV and radio, will be contributed as required, and 
in prime time, as a public service function of an FCC licensed radio or 
TV station. 

Appointment makers at all screening facilities, must be exceedingly 

careful during this phase of the demonstration to accurately ascertain the 

basis of referral of the client to the facility. The EPSDT Registration 

Sheet (Evaluation Handbook - EPSDT Demonstration Model) specifically 

provides the following options for checkoff: 

Newspaper ad 
Radio notice 
TV notice 
Mailed flier 
Letter notice 
Walk-in 

Welfare worker 
Other agency 

Specify 

Neighbor 
Other 

Speci f y 

Configuration for the case finding activities in sectors 2, 3, and 5 
are as specified in this paper for incentive payment to conmunity organiza- 
tions (7.50 per show for screen) and for full time case finding aides as 
applicable. 

Functions and Prerequisites 

- - for case finding aides and program coordinators as indicated in the 
appropriate section of this paper. 

Pre-test Training 

- - for case finding aides and program coordinators as indicated in the 
appropriate sections of this paper. 



30 



Work Performance Task Goals 



- - for case finding aides and program coordinators as indicated in the 



appropriate sections of this paper. 



Forecast : (for computation of costs, exemplification of methodology, and 
estimation of variable impact) 

Subsector Sector Total Demonstration 



Assume an average of 190 shows per week per 
sector - 190 X 26 weeks (6 months) = 4,940 

Assume 1/4 of 5,000 eligibles turnover (gains 
or losses) during the six month period and 
that, therefore, 1/4 of the 4,940 shows, or 
1,210, are not part of the eligible popula- 
tion at the end of the report period. Re- 
maining show for screen eligibles are 
3,730. Further assume that 45% of the new 
eligibles (1,210 x .45) or 544 are contacted 
and show for screening; therefore total shows 
for screens at the end of the 6 month period 

is 3,730 + 544 = 4,274 x 6 = 25,644 Total eligible popu- 

lation is 30,000. 
The number of shows 
for screen of eligibles 
at the end of 6 month 
test period is 26,644. 
25,644 ^ 30,000 = 85% 
85% rate of shows for 
screen (at the end of 
six months. 



(Caution: This forecast does not assess the impact of mass media in the specific 
sectors where it stands alone; but assesses it in the totality of the 
average of all sectors with added variations as earlier indicated) 

Costs: 

Direct 

TV program production $20,000 
Radio program production $6,000 

(No air time costs assessed - donated as public service function) 
Sector 2 costs (community organization outreach at $7.50 per show) 



Based on 1/6 of the case finding results indi- 
cated above for the total demonstration in 
this phase: 



( 



I 

I 




31 



4,940 shows (original eligibles) 

544 shows (new eligibles) 
5,484 shows x $7.50 = $41,130 

Sector coordinator (? 12,000 per year = $6,000. 
1/2 clerk typist 06,000 per year = $6,000 x 
.50) X .33 = 990. 



Sector 2 total direct costs 



41,130 
6,000 
990 
$47,220 



Sectors 3 & 5 costs (full time case finding aides) 
Labor costs (aides) per sector for 8 months 
was 12,870 and for 6 months would be 6/8 (.75) 
or 9,652 x 2 sectors = 19,304 
Total Direct Costs $19,304 



Total Direct Costs; all sectors = 



$20,000 (TV) 
8,000 (Radio) 
47,220 (Sector 2) 
19,304 (Sectors 3 & 5) 

$94,524 



Total shows for screening (all sectors, 6 months) = 32,904 



Indirect 



Total 



1 



$95,524 T 32,904 = 
$2.90 direct cost 
per show 

$2.90 X .26 = .75 

$2.90 X .75 = 3.65 



RECAP: 85% of penetration rate achieved (rate of shows for screening) 
at $3.65 average cost per show for screen. 

^Indirect cost is 26% of the direct cost (see footnote on computation of 
indirect costs in forecast section, other alternatives) 



(I 




32 



SECTION II 

The Case Monitoring Subsystem 
Subsystem : Case Monitoring 

Subsystem Objective : Altering resources and money committed to case monitoring 
will vary the costs and rates of completions for screens, problems, cases 
and rescreens. 

The Total Experiment : A comparison of the rates of completion and the costs 

per completion between persons of various educational and skill qualifica- 
tions as case monitors. 
Tested hypothesis at a = .05: 

1. jHo: Completion rates will be equal for each category of persons. 
iHa: Completion rates will be different for each category of persons. 

2. 2^^' Dollars per case completed will be equal. 
2Ha: Dollars per case completed will be different. 

Statistical tests: 



Public Health 
Nurses 


Social Workers 


Case Monitoring 
Aide (Clerical/Adm) 


No. completed 


Xu 


Xl2 


Xl3 


No. not completed 


X21 


X22 


X23 




n.i 


n.2 


n.3 



X3j^ calculated >x table* reject Ho and look further to discover 
the best rates. 

If the null hypothesis is not accepted, t test on proportions will be made 
to determine where the differences in completion rates exist. 




- \ • 



33 



Table of Proportions 
Method of case monitoring 

I 2 3 
Case completion x x x 

II 12 13 



Tested hypothesis at a = .05 

Hoj: Pj - P2 = where Pj =^ x^^ 

Hai: Pi - P2 = n.^ 

Additional tests will be made comparing all proportions with each other. 

Research Objective : Demonstrate for decision makers at all levels associated 

with EPSDT in major urban complexes the most effective and feasible means, and 

their respective costs to achieve high case (problems, screens and rescreens) 

completion rates for children with identified health problems. 

Indicator of Subsystem Performance in each of the Experimental Groups and 
in Total : 

Rate of case (problem, screen, rescreen) completions per average cost per 
completion. 

Formula to Determine Case Completion Rates and Average Cost per Completion : 

A. No of problem completions (of confirmed problems) = % (rate) of problem 

(1 ) Rate No. of confirmed problems completions 

(2) Operating costs • • Case monitoring subsystem = Average cost per problem com- 
Costs No. of problems completed pletion at rate of 

ETobJejn comBletioj] 

B. 

(1 ) Rate No. of case completions = % (rate) of case completions 

No. of confirmed cases 

(2) Operating costs • 'Case monitoring subsystem = Average cost per case completed 
Costs No. of cases completed at rate of case completion 



C. No. of screens completed = % (rate) of screens completed 

(1 ) Rate No. of shows for screening 

(2) Operating costs • • case monitoring subsystem = Average cost per screen completed 
Costs No. of screens completed at rate of screens completed 



i 



i 



34 



No of Rescreens completed = % (rate) of rescreen completions 
Rate No. of eligibles for rescreen 

Operating costs—case monitoring subsystem = Average cost per rescreen cOm- 

Costs No. of rescreens completed pleted at rate of 

rescreens completed 

Experimental Factors to be Tested 

1. Public health nurses as case monitors 

2. Social workers as case monitors- 

3. Clerical personnel as case monitors 

Little experimental or experiential data exists on rates of case com- 
pletions in EPSDT or similar programs. Nevertheless, case monitoring 
(problem, case, screen, rescreen completions) has been long recognized by 
the Health Services Research InstitiTte from its review of state programs 
and the ongoing EPSDT demonstration projects, as the major deficiency of 
the EPSDT program . Efforts were made to investigate possible means to 
rectify this situation by injecting the requirement into the ongoing 
demonstrations. The most significant finding to date (February, 1975) in 
this area is that even in the disciplined and controlled environment of 
a demonstration, children with identified serious health problems become 
"lost" in the system, following the action of referral to a provider. 
This is the weakest link in the total sequence of screening, diagnosis and 
treatment (including case/problem resolution). The implication is that 
greater emphasis must be placed on the subsystem of case monitoring and in 
demonstration's tighter procedures, varying skill groups, and staffing 
authorizations need to be tested and evaluated. 

The minimal conclusions already reached from the ongoing demonstration 
and review of state programs is that (1) the function of case monitoring 



i 



35 



must be recognized as an absolute requirement for an effective EPSDT 
program and (2) that it must be staffed with full time personnel committed 
to the function to achieve acceptable levels of case completions. 

Case completion is not a concern solely of the case monitoring sub- 
system. Procedurally, in the treatment context, it is a function of the 
treatment subsystem. And in other experimental models, consideration of 
interjecting fiscal rewards into the various provider mechanisms is 
contemplated, as a means of increasing treatment (case/problem) completion. 
However, due to limitation of funds; sensitivity of providers (individually 
and collectively) requiring lengthy negotiations; necessity for obtaining 
Medicaid waivers in the demonstration jurisdiction (time), this option will 
not be employed in this demonstration Cor will be interjected in a later 

phase if funds become available). Additionally, however, pursuit of case 
completions within the case monitoring subsystem is appropriate to estab- 
lish a cost/data base for completion rates for later comparison with rates 
and costs in the treatment subsystem. Furthermore, low rates of case 
completions (screens, problems, case^rescreens) may be more a factor of 
client failure than a treatment system failure. Significantly, increased 
rates of case completions through case monitoring activities may well 
substantiate this and the data planned for collection in this demonstration 
should provide insight into this matter. 

As conceptualized, case monitors will be expected to continually follow 
up on clients and providers to assure that a problem/case reaches 
"resolution". 

Which category of individual can best achieve a high rate of resolutions? 
Traditionally in public sector child health programs, public health nurses 
fulfill this type role. The tendency toward this category of personnel as 



36 

interest in case monitoring develops, is evident. Social workers monitor 
their welfare cases--some tendencies are evident here— but this again may 
be because of traditional roles. Can clerical personnel at a much lower 
skill and wage level and with strong identifications with the target 
populations "monitor" cases to achieve equal or better results than the 
others? 

Research Schema 

The effectiveness (case, problem, screen, rescreen completions) and 
cost of the major factors to be tested will be compared with each other to 
determine which has the highest case completion rate at the lowest cost. 
Area and Task Related Configuration 

Refer to this heading in Section I for general applicability. 

Diagrammatically, the configuration contemplated for implementation 
is as follows: 



DEMONSTRATION AREA 
SECTORS 

1 2 3 4 5 6 



Public Health Nurse 


Social Worker 


Case Monitoring Aides 
(Clerical/Adm.) 


Control -Pre Demo 
Case. Mon. Act. 


2500 Families 
5000 Children 


2500 Families 
5000 Children 


2500 Families 
5000 Children 


2500 Families 
5000 Children 


2500 Families 
5000 Children 


2500 Families 
5000 Children 


1 per sector 


1 per sector 


1 per sector 


1 per sector 


1 per sector 


Control 
(Pre-Demo) 



Time and Task Related Configuration 

The overall schema for testing of the three factors selected (with variations) 
throughout the duration of the demonstration (36 months) is portrayed in the 
following schematic: 



(I 



(l 



( 



37 



CASE MONITORING RESEARCH DEMONSTRATION SCHEMA 
SECTORS 



Time 
(Months) 



1 



PHASE I 



Data Ccl lection 



PHASE II 



Public Health Nurse 
Case Monitor 
(1 per Sector) 



- Data Basij 



Social Wrkr 
Case Monitor 
1 1 per Sector 



(2 per Sector) 



s s e s s 



(Media vari 
objective - 
sub-system) 



2 per Sector) 



m p a c t 



ahl 



I 

e has case 
but may havfe 



Case Monitjoring Aide 
(Clerical 
(1 per 



- Pre Demo Activity 



/Admi 



Control - Cont, 



ni strati ve)Pre-Demo Activity 
Sector) 



(2 per 



f mass 



inding as a 
a bonus effect 



Sector ) 



media 



primary 
on this 



\ 



38 



Constraints or Assumptions to Assure the Significance of the Findings 

Refer to the "General" Section and to this heading in Section I for general 
applicability as appropriate to "Standardization of Operating Procedures" and 
"Assumptions - Client, Locational and Staff Variables". 

The following describes the schema for establishing each of the designated 
experimental factors together with the estimated impact on the total project: 

Full time case monitors 

Objective : Establish the case completion rates that can be achieved 

by full time case monitors of specific characteristics, under specified 

conditions. 

As an ancillary objective, determine the probable output potential 
of such case monitors as expressed in workload terms, such as contacts 
per prescribed period, and the percentage of case completions per prescribed 
period at average costs per case completion. 

Configuration : Those sectors that are to be used for demonstrating 
full time case monitors will, as established previously, consist of specific 
area delineations with, at a sector level, 5P00 eligible children (2,500 
eligible families). One full time case monitor will be employed per sector 
in demonstration months 5-12 and two per sector in demonstration months 
13 - 36. Assuming an average penetration rate of 50% over the period in 
demo months 5 - 12, this configuration will provide each case monitor a basic- 
case load of approximately 1,250 cases needing treatment follow-up to comple- 
tion (5,000 children x .50 [average penetration rate] x .50 [percent assumed 
to have both medical and dental problems sufficiently significant to justify 
initiation of a problem sheet in the screening process] = 1,250) and 1,250 




(1 



f 1 



39 



needing rescreen sequence follow-up (those found "well" in the initial 
screening) = a total case load of 2,500. The primary factor of perform- 
ance evaluation of case monitoring is the case completion rate on those 
children who had problems identified in the screening process. 

The primary function of case monitors is to maintain surveillance 
over all children that "show" for screen to assure that they (1) complete 
the screening sequence and, (2) that those found with problems go to and 
complete a treatment sequence, and (3) that all children in the program 
are advised of, appear, and complete the screen and appropriate treatment, 
if indicated, and periodic rescreens (per a prescribed schedule of 
periodicity) . 

Prerequisite for Case Monitors 
Public Health Nurses 

- qualified public health nurses (this qualification dictates 

education and skill) 

- minimum of five years' experience 

- bilingual (in the language of the demonstration sector, if it is 

bilingual) 
Social Workers 

- qualified social worker (minimum of a bachelor's degree with a 

major in social science) 

- minimum of five years' experience 

- bilingual (if area is bilingual) 

Case Monitoring Aides (clerical/administrative) 

- minimum education - high school graduate 



40 



- bilingual (if area is bilingual) 

- resides within (indigenous to) demonstration area 

- two years work experience in an administrative/clerical capacity 
Pre-test Training for Case Monitors 

All case monitors will be instructed in a job preparation course of 
approximately 40 hours covering the same general ihaterial as the course 
prescribed in Section I for case finding aides, but in the job specific 
areas, focusing on case monitoring methods and techniques, quotas, etc. 
A training program of this nature is in the final stage of development by 
the School of Social Work, University of Texas at Austin. This material 
will be utilized to establish a standard case monitor - 40 hour training 
program for use in all demonstrations. 
Case Monitors - Work Performance Task Goals 

If telephone contacts only (family & provider) 48 per day 



(240 per week) 



If home visits only 



10 per day 
(50 per week) 



If combination (telephone contacts & visits) 



24 tele, contacts 



per day 
5 home visits per day 



(120 tele, contacts 
per week) 

(25 home visits per 
week) 



Cases under monitorship (case file) 
(maintained active - eligibles) 



2,500 



41 



Forecast 

Demonstration 

Sector 1 & 2 Total 

Public health nurse 



Sector 3 
Social worker 

Sector 4 & 5 

Case finding aides 



EXPERIENTIAL/EXPERIMENTAL FACTORS DO NOT EXIST TO PREDICT 
PERFORMANCE - UNTIL SUCH IS OBTAINED, ASSUME ALL SECTORS 
REFLECT 50% CASE COMPLETION RATES IN ALL CATEGORIES DURING 
DEMONSTRATION MONTHS 5 - 12 (1 PER SECTOR) AND 75% (TWO 
PER SECTOR) IN ALL CATEGORIES DURING DEMONSTRATION MONTHS 
13 - 30, AND 80% (MEDIA BONUS EFFECT) DURING DEMONSTRATION 
MONTHS 31 - 36. 



Costs : 
Direct: 



Public Health Nurse Case Monitor 
$12,000 per annum x .75 (% If 12 
X 2 (2 sectors) = 

Social Worker Case Monitor 
$10,000 per annum x .75 (% of 
X 1 (1 sector) = 

Case Monitor Aide 
$7,500 per annum x .75 (% of 
X 2 (2 sectors) = 



months) 

$18,000 



12 months) 

7,500 



12 months) 

11,250 
$36,750 



Each case worker has a 1,250 case load in the 

first year of those requiring treatment follow 

up. Assume that 50% of those are resolved = 

1,250 X .50 = 625 case completions. 

Also assume that 1/3 of 1,250 were case 

completions and not in the eligibility category 

at the end of the period (turnover), therefore 

(1250+416) 1,666 cases were brought to completion 

during the period 5-12 demonstration months. 

1,777 X 5 sectors = 8,330 $36,750 f 

8,330 = 
4.41 Direct 
cost per case 
completion 



a 



42 



Indirect : 

Assume that indirect costs of the case monitor- 
ing subsystem at 26% of the direct costs = 4.41 x 26% = 

4.41 + 1.15 
$5.56 
(Total average cost 
per case completed) 

RECAP: 50% rate of case completions achieved at $5.56 




Ill' 



SECTION III 



First 12 Month Cost Forecast (Demonstration Month 1-12) 

Project Management Costs 

Project Director $ 20,000 

Cost Analyst/Budget, Fiscal & Cost Data 16,000 

Sub Total ( 36,000 ) 

Phase II Costs (Demonstration Months 5-12) 
Case- Finding Sub System 

Direct Indirect ^ 
Sectors 1, 2, & 3 38,610 + 10,038 = 48,648 

Sectors 4 & 5 115,360 + 29,993 = 145,353 

Sub Total ( 194,001 ) 

Case-Monitoring Sub System 

Direct Indirect ^ 
Sectors 1 through 5 36,750 + 9,555 = 46,305 

Sub Total ( 46,305 ) 

Total $276,306 
(Exclusive of Evaluation) 



^Case-Finding and case-monitoring subsystem indirect costs are 26% of 
direct costs. 





i 




1